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HomeMy WebLinkAbout14-6454IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ANASTACIA MARIE -CARMAN, HERNANDEZ, a minor, deceased, 0 ,.. TUE:-F'E O i F1Ol1U TAR'.' 20111 NOV -5 PH 12: ?2 CUMBERLAND COUNTY PENNSYLVANIA No. 14- (O'+51.1 �i1Vl,« ► PETITION FOR APPROVAL OF SETTLEMENT OF WRONGFUL DEATH AND SURVIVAL CLAIMS TO THE HONORABLE JUDGE OF THE SAID COURT: AND NOW COMES, Petitioner, Progressive Advanced Insurance Company ("Progressive") by and through its legal counsel, Forry Ullman, and hereby files the instant Petition to Settle Wrongful Death and Survival Claims, and avers as follows: 1. On or about September 28, 2013, a tragic automobile accident occurred on Route 81, Butler Township, Schuylkill County, Pennsylvania. 2. Upon information and belief, the accident occurred when a 2007 Suzuki Forenza operated by the minor decedent's father, Alberto Hernandez, while traveling in a northerly direction on Route 81, went out of control, leaving the highway, striking a tree and rolling onto its roof. 3. At the time of the above-mentioned single vehicle accident, Anastacia Marie - Carman Hernandez was a passenger in the vehicle driver by her father, Alberto Hernandez. 4. As a result of the accident, both Alberto Hernandez and Anastacia Marie -Carman Hernandez sustained multiple fatal head and chest injuries and died at the accident scene. 5. Andree Dimitra Hernandez is the mother of the minor decedent, Anastacia Marie - Carman Hernandez and letters of administration have been issued to her on September 8, 2014. 4; 115.'75 PIS P;11 CSP le 313037 A copy of the Short Certificate granting the letters administration of the estate is attached hereto as Exhibit 1. 6. It is believed and therefore averred that the minor died intestate and Andree Dimitra Hernandez is the only person entitled to recover any monies under Pennsylvania law and, furthermore, because the decedent was under 21 at the time of her death and was survived by her mother, any probate assets that were to pass to her parent as her intestate heirs would be subject to inheritance tax at a zero % tax rate. 72 P.S. §9116 (1.2). 7. As alleged hereinabove, the decedent, Anastacia Marie -Carman Hernandez, (being born on October 17, 2012, Social Security No.: xxx-xx-4005), was pronounced dead September 28, 2013. Attached hereto as Exhibit "2" is a true and correct copy of the Police Accident Report and Attached hereto as Exhibit "3" is a true and correct copy of the Certification of Death. 8. At the time of the accident, the minor decedent resided at 417 Ricky Road, Upper Allen Township, Cumberland County, PA 17055 with her parents Alberto Hernandez, deceased, and Andree Dimitra Hernandez 9. Decedent died intestate, with her only intestate heir being her mother and natural guardian Andree Dimitra Hernandez 10. At the time of the accident, the vehicle involved in the subject accident was insured by Petitioner Progressive under policy no. 31446116-3, that was issued to Andree Dimitra Hernandez, with BI limits of $25,000.00 per person, $50,000.00 per accident. Attached hereto as Exhibit "4" is the applicable Coverage Summary/Declarations Page. 11. At the time of the accident, upon information and belief, there were no other automobile policies in the household. 12. Further, upon information and belief, there was no other policy of insurance providing uninsured and/or underinsured motorist coverage. 13. Petitioner Progressive has agreed to tender the applicable liability policy limits of $25,000.00 under the liability provisions of the automobile policy issued to Andree Dimitra Hernandez. (See Exhibit "4"). 14. The Department of Public Welfare ("DPW") has not asserted any lien against any of the settlement proceeds in the instant proceeding. Attached hereto as Exhibit "5" is a true and correct copy of the correspondence from DPW. 15. No other entity has come forward and asserted any lien against any of the settlement proceeds. 16. Moreover, the Pennsylvania Department of Revenue does not challenge the allocation between Wrongful Death and Survival Actions in the instant matter. Attached hereto as Exhibit "6" is a true and correct copy of the correspondence from the Pennsylvania Department of Revenue evidencing this position in regard to the Estate's settlement for the $25,000.00 in liability coverage under the policy issued to Andree Dimitra Hernandez. 17. Andree Dimitra Hernandez has not been made aware of any unpaid or outstanding claims which are raised against the minor decedent, and the minor decedent's EMT medical bill was paid by Progressive under the first party medical provisions of the policy. 18. Andree Dimitra Hernandez is of the opinion that the proposed settlement is fair and reasonable. 19. The Petitioner, Progressive, has retained Forry Ullman to prepare the instant Petition. However, Forry Ullman, has neither acted as legal counsel nor given any legal advice to Andree Dimitra Hernandez throughout the settlement process. 20. There are no outstanding funeral expense for the minor decedent. 21. The wrongful death beneficiary, Andree Dimitra Hernandez does not owe any child support arrears according to the PACSES website. See Exhibit "7". 22. The Petitioner, Progressive, upon the request of and with the consent of Andree Dmitra Hernandez respectfully requests allocation of One Hundred Percent (100%) of the net proceeds of the settlement to be paid to the wrongful death action as follows: a. Wrongful Death Action: $25,000.00 b. Survival Action $ 0. 23. The rationale behind this allocation is as follows: to minimize possible taxes, paperwork and checks. 24. The allocation notwithstanding, Andree Dimitra Hernandez has agreed to execute a general release of all claims, including wrongful death and survival action claims, against Alberto Hernandez. A copy of the Proposed Release is attached hereto as Exhibit "G." 25. Pursuant to the Wrongful Death Statute (42 Pa.C.S.A. §8301), the beneficiaries of the Wrongful Death Claim are their respective proportions are as follows: TO: Andree Dimitra Hernandez (mother of decedent) $25,000.00 Total: $25,000.00 26. Non -disclosure of terms is not a condition of settlement. 27. Andree Dimitra Hernandez completely understands that if this Honorable Court approves the instant Petition and the Settlement/Allocation proposed herein, there shall be no further claims whatsoever asserted and/or allowed against the parties named in the Release Agreement attached hereto, arising from the subject accident, the injuries suffered therein, or thereafter, and/or from the Decedent's death. WHEREFORE, Petitioner requests that this Honorable Court approve the settlement and distribution of the settlement proceeds, proposed herein and that the Court enter an Order of Distribution as follows: TO: Andree Dimitra Hernandez (mother of decedent) $25,000.00 Total: $25,000.00 FORRY ULLMAN By: RANDY T. BURCH, ESQUIRE Attorney I.D. No. 59567 P.O. Box 542 Reading, PA 19603 (610) 777-5700 - Attorneys for Progressive WRITTEN ACKNOWLEDGEMENT AND CONSENT I, Andree Dimitra Hernandez, individually and as mother and natural parent of Anastacia Marie -Carmen .Hernandez, deceased, acknowledge that I have read the Petition (ac‘w►2n for Approval of Settlement of Wrongful Death and Survival. Claims and understand its contents, and furthermore I consent to the Court approving the Petition and settlement of this matter. NDREE DIMITRA HERNANDEZ Individually and as Parent and Natural Guardian of Anastacia Marie Gafff Hernandez, deceased earw314 Dated: VERIFICATION I, RANDY T. BURCH, ESQUIRE, attorney for Progressive Advanced Insurance Company, hereby certify that the information set forth in the foregoing Petition are true and accurate to the best of my knowledge, information and belief. I understand that the statements made herein are subject to the penalties of 18 Pa.C.S.A §4904 relating to unsworn falsification to authorities. o.u.11lyrn FORRY ULLMAN RANDY T. BURCH, ESQUIRE EXHIBIT " REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA Certificate of Grant of Letters No. 21-14-0831 PA No. 21-14-0831 ESTATE OF Anastacia Marie -Cannan Hernandez a/k/a: Late Of: Upper Allen Township, Cumberland County, Deceased Social Security No. 024-11-4005 WHEREAS, Anastacia Marie -Carman Hernandez, , late of Upper Allen Township, Cumberland County, died on the 28th day of September, 2013, and WHEREAS, the grant of Letters of Administration is required for the administration of the estate. THEREFORE, I, Lisa M. Grayson, Esq., Register of Wills in and for the County of Cumberland, in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to Andree Dimitra Hernandez, who has duly qualified as Administratrix of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my Office at Cumberland County Courthouse, Carlisle, Pennsylvania. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of any office the 8th day of Setember, 2014. Wot(! la Register /C/\ -Lae Depu * * NOTE** ALL NAMES ABOVE APPEAR (F 1) COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND Hernandez I, Lisa M. Grayson, Esq. Register for the Probate of Wills and Granting of Letters of Administration in and for Cumberland County, do hereby certify that on the 8th day of September, 2014, LETTERS Administration in common form were granted by the Register of said County, on the estate of Anastacia Marie -Carman Hernandez , late of Upper Allen Township in said county, deceased to Andree Dimitra and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, Pennsylvania, this 8th day of Setember, 2014. Date of Death: September 28th, 2013 Social Security No. 024-11-4005 Estate No. 21-14-0831 /UK 44 ati.,0-hpL Register E Deputy NOT VALID WITHOUT ORDINAL SIGNATURE AND IMPRESSED SEAL EXHIBIT "2" AA -500 TX Incident Number L03-1291182 Crash Involves: 0 DUI 0 Fatality 0 Hit and Run °Commercial Vehicle Commonwealth of Pennsylvania Police Crash Report ON1A °Work Zone 0A1V °Snowmobile 13-74igil 70 • PAGE 1 REPORTABLE CRASH °State Police Vehicle 0 Local Police Vehicle Commonwealth Vehicle )Local Gov Vehicle 19 'A Agency Name PA STATE.POLICE - FRACKVILLE Case Closed YES Patrol Zone .71 Investigation Date 09/28/2013 Dispatch Time . 10:51 hrs. Antral Time 10;57 hrs. Investigator HARDNOCK, PAUL Badge Number 10209 3 — Approval Date 10/24/2013 Reviewer GAUNTLETT, PAUL P Reviewer Badge Number 05917 Date of Crash 09/28/2013 Time of Crash 10:50 hrs. Day of the Week SATURDAY Crash Description HIT FIXED OBJECT County SCHUYLKILL Munic:laity BUTLER TWP ..7, B Weather Conditions NO ADVERSE CONDITIONS Relation to Roadway ROADSIDE .c 0 O Illumination \Road DAYLIGHT Surface Conditions DRY N of Units 001 # of People 002, St of Injured 000 N Killed 002 EMS Agency FRACKVILLE, SHENANDOAH EMS Medical. Facility NONE • School Bus Related NO School Zone Related NO PannDOT Notified NO Type of intersection MIDBLOCKNOT ' Special Location APPLICABLE I Work Zone Work Zone NO Work Zone Type Where in VVeitZone - Speed Limit Workers Present Officer Present Nor* Zone Characteristics 1--iRoad Closed r.-1 Work on Shoulder Lone Clesure I_J with Detour L....I or Med intermittent or ri nagger Mcng Work 1...-I Control Oth Route Signing INTERSTATE(NOT TURNPIKE) Route Number 0081 Segment Number 0121 Travel Lanes 02 Speed Limit 65 MPH Orientation NORTH House Number Street Name I-81 St. Ending HIGHWAY ' Used in 'intersection Route Signing Route Number Segment Number Travel Lanes Speed Umit Orientation Crashes Street Name St. Ending Distance From Landmark 1 1 2 '8 --) fROute Number Dr Mile Post Tenths Or Segment Marker Ramp Use Only Feet -5 Street Name BEAVER DAM Street Ending ROAD DrIoUles 00 Tenths 2 Landmark 2 Route Number 0061 Or Mile Post Tenths Or Segment Marker Ramp Use Only . The above entry is the distance from the Crash Scene to Landmark 1 Street Name SR 0061 Street Ending HIGHWAY Latitude:• Degrees 40 Minutes 45 e C Seconds 34 • Decimal 913 L ongitude: m Degrees 76 Minutes 16 •Seconds • • 37 . Decimal 010 \Traffic Control Device NOT APPLICABLE Traffic Control Functioning NO CONTROLS o Lane Closed PARTIALLY Lane Closure Direction NORTH Traffic Detoured NO Estimated Time Closed 1-3 HRS Environmental / Roadway Potential Factors (EJR) Factor I NONE Fedor 2 Factor 3 First Harmful Event In the Crash Most Harmful Event In the Crash Unit Number 001 Harmful Event HIT DITCH Unit Number Ilarrntui 001 Event OVERTURN/ROLL OVER Indicated Prime Factor DRIVER ACTION Unit Number 001 Prime Factor Driver Action DRIVER WAS DISTRACTED W Prime Factor EnvIrornentaVRoachvey Prime Factor Vehicle Failure Prime Factor Pedestrian Action Road Surface Type BLACKTOP Special Jurisdiction NO SPECIAL JURISDICTION Printed At PA STATE POUCE - FRACKVILLE 11/19/2013 7:43 AM Form # L03-1291182 AA -500 TX- Incident XIncident Number: L03-1291182 Crash Involves: °:DUI +} N/A j Fatality Work Zone Commonwealth of Pennsylvania Police Crash Report Mt and Run 0 -ATV °Commercial Vehicle °Snowmobile REPORTABLE CRASH 0 State Police Vehicle °Commonwealth Vehicle PAGE 2 Police Vehicle Gov Vehicle iDamage c 0 .' Unit Number 1 Type Una Motor Vehicle in Transport Commercial Vehicle • No First Name ALBERTO MI Last Name HERNANDEZ Suffix DOB 01/11/1971 Telephone Number (717) 7664912 Street Address 417 RICKY ROAD par MECHANICSBURG State PA 27p Code 17055 IGender M IJcenee Number 2407034 Jcense State PA lass C Expiration Date 01/12/2017 Owner/Driver PRIVATE VEHICLE NOT OWNED/LEASED BY DRIVER Driver Presence DRIVER OPERATED VEHICLE Physical Condition UNKNOWN Primary Vehicle Code Violation 3714 - CARELESS DRIVING Person Charged NO Alcohol/Drugs Suspected NO Alcohol Test Type TEST NOT GIVEN Alcohol Test Results DriverAdron DRIVER WAS DISTRACTED Pedestrian Action Pedestrian Signals Pedestrian Clothing 'Utility Pedestrian Location 1st Hamdui Event HIT DITCH Left or Right Side LEFT Most Harmful NO Pole Number • 2nd Harroful Event HIT TREE OR SHRUBBERY 1Left or Right Side RIGHT Most Harmful NO Utility Pole Number 3rd Harmful Event OVERTURN/ROLL OVER Lea or Right Side Most Harmful YES Utility Pole Number 4th Harmful Event Left or Right Side Most Harmful Utility Pole Number iDamage c 0 .' Owner First Name ANDREE Owner MI D Owner Last Name or Business Name CARMAN ouKor Street Address 417 RICKY ROAD City MECHANICSBURG Stale PA Zlp Code 17055 Vehicle Type AUTOMOBILE Special Usage NOT APPLICABLE Government Equipment Number Model Year 2007 Vehicle Make SUZUKI Vehicle Model FORENZA Vehicle Color GOLD VIN KL5JD56Z27K560795 Jcense Plate GCK6679 Reg. Stale PA Est. Speed 072 Vehicle Towed YES Towed By STEVE'S TOWING Insurance YES Insurance Company PROGRESSIVE ADVANCED LNSURANCE 'Pokey Number 31446116-3 Expiration Date 11/0212013 Direction of Travel NORTH Vehicle Position LEFT LANE Vehicle Movement GOING STRAIGHT Initial Impact Point 6 O'CLOCK Indicator DISABLING Gradient LEVEL Road Alignment STRAIGHT Possible Vehicle Failures NONE Trailing Units if of Units 0 Type tine 1 Tag Number Tag Year Tag State Unit Make Unit Owner Type Unit 2 Tag Number Tag Year Tag State Unit Make Unit Owner u E g b 2 Engine Size cc Passenger? Saddle BagfTrunk? Trailer? Driver Education? Driver Helmet Type Helmet Stayed On? DOT/Snell Designation? ' Eye Protection? Long Sleeves? Long Pants? Over Ankle Boots? Passenger Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? tong Pants? Over Ankle Boots? Y u T V a Passenger? Helmet? Head Lights? Rear Reflectors? Printed At PA STATE POUCE - FRACKVILLE 11/19/2013 7:43 AM 2 Form it L03-1291182 , . AA-500,TX Incident Number L03-1291182 Commonwealth of Pennsylvania PAGE 3 Crash Involves: Police Crash Report REPORTABLE CRASH ODUI ()Fatality 0 Hit and Run °Commercial Vehicle °State Police Vehicle °Local Police Vehicle ONJA ()Work Zone 0 ATVSnowmobile Qcoinmonwealih Vehicle Q Local Gov Vehicle Unit# 1 Driver Restrictions Compliance UNKNOWN COMPLIANCE Driver Endorsement Compliance NONE REQUIRED Driver Ucense Compliance VALID LICENSE FOR CLASS Principal Impact Point 6 O'CLOCK u.. Emergency Use NOT IN EMERGENCY USE Avoidance Maneuver STEERING AND BRAKING - EVIDENCE OR STATED Under Ride indicator NO UNDERRIDE OR OVERRIDE Drug Test Type NONE Drug Test Results NO TEST GIVEN Unit tiNo. 001 re371 n First Name ALBERTO MI Last Name HERNANDEZ Suffix DOB 01111/1971 -beet Address 417 RICKY ROAD City MECHANICSBURG State PA Zip Code 17055 Phone Number (717) 766-4912 EMS Transport NO Person Type DRIVERM Gender Injury Severity KILLED Seat Position DRIVER - ALL VEHICLES Safety Equipment 1 NONE USED I NOT APPLICABLE Safety Equipment 2 FRONT AIR BAG DEPLOYED (FOR THIS SEAT) Extrication NOT EXTRICATED Ejection TOTALLY EJECTED Ejection Path THROUGH SIDE WINDOW g % € ,2 r Unit* 001 Person No. 002 First Name ANASTACIA MI M Last Name CARMAN Suffix DOB 10/17/2012 ^treet Address 417 RICKY ROAD City MECHANICSBURG State PA Zip Code 17055 Phone Number (717) 766-4912 EMS Transport NO Person Type PASSENGER Gender F injury Severity KILLED Seat Position SECOND ROW - RIGHT SIDE Safety Equipment 1 CHILD SAFETY SEAT USED Safety Equipment 2 NONE USED / NOT APPLICABLE Extrication FREED BY NON-MECHANICAL MEANS Ejection NOT EJECTED Ejection Path NOT EJECTED/NOT APPLICABLE a First Name MICHAEL Ml A Lest Name HOLM Sid& Phone Number 4844648248 Street Address 1231 SKYVIEW DRIVE City SCOTRUN State PA Zip Code 18355 a First Name AUCIA Mi M Last Name BROUGHTON Suffix Phone Number 3152479494 street Address 7462 AMBROSE DRIVE City MECHANICSVILLE State rip Code VA 23111 • Printed At: PA STATE POLICE - FRACKVILLE 11/19/2013 7:43 AM 3 Form # L03-1291182 Personzusiness Notified ANDREE DIMITRA HERNANDEZ Phone Number (717) 766-4912 Date Notified 09/28/2013 Time Naffed 21:00 hrs. Reason for Notification DEATH NOTIFICATION COMPLL I tU BY PSP CARLISLE • Printed At: PA STATE POLICE - FRACKVILLE 11/19/2013 7:43 AM 3 Form # L03-1291182 AA -500 TX Incident Number: Crash Involves: L03-1291182 0 DUI @ Fatality O UA QWork Zone Commonwealth of Pennsylvania Police Crash Report REPORTABLE CRASH O'State Police Vehicle 0Commomvealth Vehicle 0 Hit and Run IDATV ()Commercial Vehicle °Snowmobile PAGE 4 0 Local Police Vehicle Local Gov Vehicle Q NARRATIVE Crash Synopsis This one vehicle crash occurred as Unit #1 was traveling north on 141 in the left lane at approx. 72MPH. For an unknown reason, Unit #1 lost control and traveled off the left berm. Unit #1 re-entered the left lane of 141 and spun counterclockwise off the left berm where it lightly struck a ditch with the rear of the vehicle. The vehicle continued to spin counterclockwise and struck a tree with its passenger side. This impact caused the vehicle to roll onto its roof. Unit #1 came to rest In the median on Its roof facing a southeastern direction. Crash Details This one vehicle crash occurred as Unit #1 was traveling north on 1-81 In the left lane at approx. 72MPH. For an unknown reason, Unit #1 lost control and traveled off the left berm. Unit #1 re-entered the left lane of 1-81 and spun counterclockwise off the left berm where it lightly struck a ditch with the rear of the vehicle. The vehicle continued to spin counterclockwise and struck a tree with its passenger side. This Impact caused the vehicle to roll onto Its roof. Unit #1 came to rest in the median on its roof facing a southeastern direction. Physical evidence 1 observed at the scene consisted of Unit #1 at its aforementioned position of final rest. Unit #1 sustained heavy damage to the passenger side and roof area. Unit #1 had three bald tires. The good tire was located on the passenger side front. The drivers seat belt appeared to be in the retracted position. 1 also observed that the seat belt on the passenger side rear seat was stressed due to the child safety seat being used in this position. I also observed approx. 119 feet of tire marks In the dirt on the left berm. There was an additional 174 feet of skids marks in the left lane. I observed an additional 124 feet from the roadway Printed At PA STATE POLICE - FRACKVILLE 11/19/2013 7:43 AM 4 Form # L03.1291182 AA -500 7X Incident Number. Crash Involves: L03-1291182 Commonwealth of Pennsylvania Police Crash Report REPORTABLE CRASH :State Police Vehicle 0 Local Police Vehicle Commonwealth Vehicle 0 Local Gov Vehicle DUI @ Fatality C'Htt and Run ON/A ()Work Zone J'ATV ()Commercial Vehicle OSnowmoblle PAGE 5 Crash Details to the Impact with the tree. Unit #1 traveled an additional 14 feet from the tree to the point of final rest. On 09/28/13 at approx 1110hrs I interviewed witness #1 at the scene. Witness #1 related that he was traveling northbound on 1-81 In the left lane approx. 150 feet behind Unit #1•. Witness #1 related that it appeared that Operator #1 was reaching for something In the passenger side and lost control of the vehicle. Witness #1 related that Unit #1 traveled off the left berm and into the gravel. Witness #1 related that Unit #1 re-entered the left lane of 1-81 northbound and spun counterclockwise into the median. Witness #1 related that the rear end of Unit #1 struck a small ditch. Witness #1 related that Unit#1 continued to travel northbound and struck a tree with the passenger side rear door area. Witness #1 related that this impact caused Unit #1 to flip onto its roof. Witness #1 related that he immediately stopped to render aid. Witness #1 related that Operator #1 was ejected from the vehicle, while the rear seat passenger was still inside the vehicle restrained in the child safety seat. On 09/28/13 at approx.1120hrs I Interviewed Witness #2 at the scene. Witness #2 related that she was traveling northbound on 1-81 in the right lane approx. 500 feet behind Unit #1. Witness #2 related that Unit #1 veered off the left side of the road. Witness #2 related that it appeared as if Operator #1 tried to regain control and could not. Witness #2 related that Unit#1 spun counterclockwise off the left berm and struck a tree. Witness #2 related that after impact with the tree, Unit #1 rolled onto its roof. On 09/28/13 at approx 1205hrs Schuylkill County Deputy Coroner Andrew SZCZYGLAK pronounced Alberto HERNANDEZ dead at the scene in the Shenandoah ALS unit # 64-01. On 09/28/13 at approx 1205hrs Schuylkill County Deputy Coroner David TRUSKOWSKY pronounced Anastacia HERNANDEZ dead at the scene In the Frackville Ambulance unit# 43-03. On 09/28/13 at 1600hrs Schuylkill County Deputy Coroner Andrew SZCZYGLAK contacted me in reference to this crash. SZCZYGLAK related that both Alberto HERNANDEZ and Anastacia HERNANDEZ were given virtual autopsies at Schuylkill Medical Center - South. SZCZYGLAK related that the cause of death for both occupants is blunt force traumatic Injuries to head and chest. On 09/29/13 at approx. 1000hrs I interviewed Alberto Miguel GUARD, 10/31/90, 30 Stark Street - Wilkes-Barre, PA 18702, 484-602-8396, via telephone. GUARD is the son of Alberto HERNANDEZ GUARD related that Alberto HERNANDEZ had worked the midnight shift at Fed -Ex. GUARD related that after work, HERNANDEZ drove his wife to work, then picked up his daughter, Anastacia HERNANDEZ, and was driving to Wilkes-Barre to GUARD's residence. GUARD related that fatigue may have been a factor in thls crash. Death Notification was completed by Tpr. BOARDMAN - PSP Carlisle on 09/28/13 at approx. 2030hrs. This incident was entered Into the PSP Fatal Crash System on 09/29/13 at 1055hrs. The scene was photographed and the master copies of these photos was submitted to the PSP Reading FSU unit photo file. A working copy of these images were placed In the photo file at PSP Frackville. SP7-0015 issued toAndree Dimitra HERNANDEZ, next of kin of Operator #1, by mail. Operator #1 had a valid PA drivers license; however, no drivers license was located at the scene. News release prepared and posted. Assisted at the scene by Englewood, Altamont, Minersville and Pottsville Fire Depts., Frackville Ambulance and Shenandoah ALS. Assisted by Steve's Towing. Printed At PA STATE POLICE - FRACKVILLE 11/19/2013 7.43 AM 5 Form # 103-1291182 � Y / { :�my AA -500N TX Incident Num ben L03-1291182 -Supplementing Officer Agency PA STATE POLICE - FRACKVILLE Commonwealth of Pennsylvania Police Crash Report Supplemental Narrative Page 1 Supplementing Officer LUCiANi, LEO Sedge Number 04371 nvesiigation Date 9/23/2013 Originating Agency PA STATE POLICE - FRACKVILLE Originating Officer TROOPER PAUL HARDNOCK Reviewer GAUNTLETT, PAUL P Reviewer Badge Number 05917 4pproval Date 10/24/2013 Narrative On 09/28/13 efforts were undertaken to effect notice of the death of Operator #1, Alberto HERNANDEZ, and obtain the Identification of the deceased female infant passenger. Contact was made with Troop H, York, as the listed address of Operator #1 HERNANDEZ would be within that bailiwick. From Troop H York it was learned the Lewisberry address was not valid. Contact was then made by telephone with Officer WOODRUFF of the Upper Allen Township, Cumberland County, Police as the address of the registered owner of Unit #1 was within that municipality. Officer WOODRUFF returned with information that his Department was familiar with the address and while gathering this Information a complaint of an over -due motorist had been received from the address of the owner of Unit #1. A short time thereafter on 09/23/13 telephone contact was received from Trooper John BOARDMAN, Troop H, Carlisle, who advised that notification had been effected and provided the identification information of Anastacia Marie -Carman HERNANDEZ, age 11 months, born 10/17/2012, the daughter of Operator #1 HERNANDEZ, as the deceased infant child. Trooper BOARDMAN also elaborated that Operator #1 HERNANDEZ had worked the night shift at Fed -Ex, dropped his wife, Andree Dlmitra HERNANDEZ, off at work in the morning, and was enroute to Wilkes Barre, PA to pick up his 22 year-old son. Schuylkill County Coroner Andrew SZCZYGLAK of Shenandoah was advised of the notification and identification. Point-to-point teletype messages were exchanged with Troop H York and Carlisle consistent with Department regulations. An updated SP7-518, Public Information Release was published. PA STATE POLICE - FRACKViLLE 11(1912013 7:43 AM 1 L03-1291182 EXHIBIT "3" LOCAL ii'EGISTRAITS CERTIFICATION OF DEATH WARisliNG: 0 is illegal to duplioatethiS dOpyb pkotostat or photograph. • Fee, for this. certificate, WOO P 19722189 Certification Number e • < ; ••• c ' ' •.` .• .'„ '•• ••••••! PePektsOt moment C01.4140MMAL TN OP POUISTINAMA • OZPARIMENT OF REAM • VITAE RECORDS CERTIFICATE OF DEATH This is.: to, certify that the information here given it correctly copied from an original Certificate of Deatt duly filed witty m:e as Local Registrar. The original ceffificate -MD be' forwaided to the State Vita Records Office for permanent filing. e;# Local Registrar Date Issued /014 /13 Sate Me Nontler, ; F.J. • :'', . ..e, . .. a te I -Decedent's Losat Name ( Int. MIMEO. lett. SWIM tO.oD Anastacia 14!krie-Cannan Hernaniez iza e s.sodo Smelly Number 024 - 11 - 4005 4. Orte of eath IlAategytel MVO.* Sept. 28, 2013 ea. rigs -Lost iirthem (TM SE. Under 1 Tmr Sr.. Under &O.y IT Date ot OM Prio/Daytheri ISIMMOOM14 Te. MEM. Mee eoP Mote Or Rodin Orimoli Months Dm Moors Mbhoes... Hershey, PA .. 0' . 11 11 , ... '•attokier..t7. 20.12 ..' 76J41,10.. ("...14 Dauphin re.tr. or Forger Emmy) how.!ma ...VW, I •W•• 0-Vai'lLa in. Resieenee ISOM MMus, InchrithrilriAcT., .., - . 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Cate Mined thieiloayay .. • Sept. 28 2013o,/. 40.plefstres bestrlo member 41. 7,x., ii .,..q. de.A....E.s.: , • •• • -... ., Ai. etegistrae FN. aste, Moh,nrni. id Pi i'13 > ., 40.1300000000 °boost]. Pero* M. 0942464 H1thelPS WU whom ••••••: E.h.• •••• •,.•• ••• ?•••• 1' , . . ••• • < • EXHIBIT "4" PROGRESSIVE P.O. BOX 31260 TAMPA, FL 33631 ANDREE D HERNANDEZ 417 RICKY RD MECHANICSBURG, PA 17055 Auto Insurance Coverage Summary This is your Renewal Declarations Page PPOORI/1pE° DIRECT .... Policy Number: 31446116-3 Underwritten by: Progressive Advanced Insurance Co March 27, 2013 Policy Period: May 2, 2013 - Nov 2, 2013 Page 1 of 3 progressive.com Online Service Make payments, check billing activity, update policy information or check status of a claim. 1-800-776-4737 For customer service and claims service, 24 hours a day, 7 days a week. The coverages, limits and policy period shown apply only if you pay for this policy to renew. Your coverage begins on May 2, 2013 at 12:01 a.m. This policy expires on November 2, 2013 at 12:01 a.m. Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle, unless the policy contract or endorsements indicate otherwise. The policy contract is form 9610D PA (05/06). The contract is modified by forms Z357 (01/07), Z445 PA (03/07), Z538 (10/08), Z763 PA (05/09) and 4884 (10/08). COLLISION COVERAGE FOR RENTAL VEHICLES IF THIS POLICY PROVIDES COLLISION COVERAGE, IT WILL APPLY TO VEHICLES YOU RENT, BUT NOT TO VEHICLES RENTED FOR 6 MONTHS OR MORE. FRAUD NOTICE Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Underwriting Company Progressive Advanced Insurance Co P.O. Box 31260 Tampa , FL 33631 1-800-776-4737 Drivers and household residents Additional information ANDREE D HERNANDEZ First Named insured ALBERTO HERNANDEZ Form 6489 PA (12/10) Continued Outline of coverage 2007 Suzuki Forenza VIN KL51D56Z27K560795 Primary use of the vehicle: Commute Limits Policy Number: 31446116-3 ANDREE D HERNANDEZ Page 2 of 3 Deductible Premium Liability To Others Bodily Injury Liability Property Damage Liability $25,000 each person/$50,000 each accident $25,000 each accident $283 First Party Benefits Medical Expenses $5,000 each person 54 Uninsured Motorist - Stacked $25,000 each person/$50,000 each accident 10 Underinsured Motorist - Stacked $25,000 each person/$50,000 each accident 14 Comprehensive Actual Cash Value Comprehensive Window Glass $500 $0 glass 49 Collision Actual Cash Value $500 253 Rental Reimbursement up to $30 each day/maximum 30 days 27 Roadside Assistance 5 Total premium for 2007 Suzuki 1991 Acura Integra VIN IH4DB1650MS010914 Primary use of the vehicle: Pleasure Limits $695 Deductible Premium Liability To Others Bodily Injury Liability Property Damage Liability $25,000 each person/$50,000 each accident $25,000 each accident $251 First Party Benefits Medical Expenses $5,000 each person 50 Uninsured Motorist - Stacked $25,000 each person/$50,000 each accident 6 Underinsured Motorist - Stacked $25,000 each person/$50,000 each accident 9 Total premium for 1991 Acura $316 Total 6 month policy premium $1,011.00 Premium discounts Policy 31446116-3 Multi -Car, Continuous Insurance: Gold, Paperless and Electronic Funds Transfer (ER) Vehide 2007 Suzuki Forenza Airbag 1991 Acura Passive Seat Belts Integra Lienholder information We send certain notices such as coverage summaries and cancellation notices to the following: Vehicle Lienholder 2007 Suzuki Forenza TOYOTA MOTOR CREDIT KL5JD56Z27K560795 ATLANTA, GA 30348 Form 6489 PA (12/10) Continued Policy Number: 31446116-3 ANDREE D HERNANDEZ Page 3 of 3 Tort Option This policy provides limited tort insurance. Information Regarding Your Premium A surcharge of $324.00 due to violations or accidents is included in the total policy premium. Notice of Available Premium Discounts You may be eligible for discounts mandated by Act 6 of 1990: • on first party benefits coverage if your car is equipped with a passive restraint system • on comprehensive coverage if your car is equipped with a passive anti -theft device • if all named insureds are 55 or older and have successfully completed a motor vehicle driver improvement course approved by PennDOT. If you have any questions about your eligibility, please call Customer Service. Company officers addvi'N\- President Form 6489 PA (12/10) Secretary EXHIBIT "5" June 12, 2014 FORRY ULLMAN RANDY T. BURCH 540 COURT ST PO BOX 542 READING PA 19603 Dear Attorney Burch: C:; W£f.;1 AAB Re: Anastacia Hernandez SSN: ###-##-4005 Co°a311 Pursuant to your letter dated June 12, 2014, the Department of Public Welfare (DPW), Third Party Liability (TPL) - Casualty Unit, has reviewed the information you provided regarding the above -referenced individual. Based on this information, we have no record of this individual receiving medical and/or cash benefits at this time. Therefore, the Department's TPL - Casualty Unit has no claim on this individual. If your client applies for medical assistance at a later date or currently has an application pending, please advise us and provide any additional information that may affect a recovery by our department. If you have any questions, please feel free to contact me. Sincerely, K _!L o 1 Vince A. Porter Recovery Section Manager (717)772-6604 Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 I Harrisburg, Pennsylvania 17105-8486 EXHIBIT "6" p+ennsy lvania DEPARTMENT OF REVENUE October 16, 2014 Randy Burch, Esquire Pony Ullman 540 Court Street PO BOX 542 Reading, PA 19603 Re: Estate of Anastasia Hernandez File Number 2114-0831 Court of Common Pleas Cumberland County Dear Mr. Burch, 6©277 The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above -referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 11 month old decedent died as a result of a motor vehicle accident. The sole heir to decedent's estate is her parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $25,000.00 to the wrongful death claim and $0 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. § 8302; 72 P.S. § 9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Sinc y, h. d'ri ake Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes 1 Po Box 280601 1 Harrisburg, PA 17128 ( 717.783.5824 1 sPabaker@pa.gov EXHIBIT "7" Pennsylvania Child Support Program Page 1 of 1 PA Child Support Program Lien Search Results As of 31.00T• 14 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications Of gged In As: JEN ARENSCHIELD arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. § 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1(a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1(h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria a Print Print AN Last Name: hernandez First Name: andree Social Security Number:. Date of Birth: Return To Liens Search No Results has been found for your Search Criteria The data is as of 31 -OCT -14. Please try again with different criteria. https://www.humanservices.state.pa.us/CSWS/lien controller.aspx?Pageld=docketlien%2f... 11/3/2014 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re: ANASTACIA MARIE -CARMAN HERNANDEZ, a minor, deceased AND NOW, this IOth day of No. 14-(01154 aiv ITrn ORDER f v Q VQ. vA\Akt , 2014, upon consideration of the Petition to Approve Settlement of Wrongful Death and Survival Actions, presented by Randy T. Burch, Esquire counsel for Progressive Advanced Insurance Company, regarding the death action claim of Anastacia Marie -Carman Hernandez, a minor, deceased, IT IS ORDERED that the settlement of the third party liability claim of Andree Dimitra Hernandez, individually and as parent and natural guardian, for the gross sum of $25,000 is approved, and is allocated 100% to the wrongful death claim' and shall be distributed as follows: WRONGFUL DEATH ACTION of ANASTACIA MARIE -CARMAN HERNANDEZ, a minor, deceased: TO: Andree Dimitra Hernandez (mother of decedent) $25,000.00 Total Wrongful Death Action: $25,000.00. ' Because the decedent was under 21 at the time of her death and was survived by her mother, any probate assets that were to pass to her parent as her sole intestate heir would be subject to inheritance tax at a zero % tax rate. 72 P.S. §9116 (1.2). Because there is no inheritance tax consequence of the allocation of these proceeds, and because the 11 month old decedent had no creditors, this allocation is deemed appropriate. IT IS FURTHER ORDERED that Andree Dimitra Hernandez is directed to execute the release and any other documents that are required to complete this settlement. Orry unn44.4 6)Py nvol-e4 BY THE COURT: \\K C) -7`