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HomeMy WebLinkAbout14-6457THOMAS, THOMAS & HAFER, LLP John F. Yaninek, Esquire Attorney I.D. No. 55741 P.O. Box 999 Harrisburg, PA 17108-0999 (717) 441-3952 r -..: D -OF _'C OF THE iROTHCHO FAITY 20114 NOV -5 PM 12: 25 CUMBERLAND COUNTY Attorneys for Estate of Baby -Girl Dias`LVON 1A IN RE: ESTATE OF BABY -GIRL DULAM- KASIREDDY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENSYLVANIA No. 14 - 69,6r a•tvilTervvi PETITION FOR APPROVAL OF WRONGFUL DEATH AND SURVIVAL CLAIMS AND NOW, comes Bharath Kasireddy, Administrator of the Estate of Baby -Girl Dulam- Kasireddy and Nationwide Property & Casualty Insurance Company, and through their counsel, Thomas, Thomas & Hafer, LLP and respectfully requests Court approval of the settlement of wrongful death and survival claims based on the following: 1. The Petitioners are Bharath Kasireddy, Administrator of the Estate of Baby -Girl Dulam- Kasireddy, and Nationwide Property & Casualty Insurance Company. 2. The decedent, Baby -Girl Dulam-Kasireddy, a 6.5 month old fetus died on September 29, 2013 as a result of injuries sustained in a motor vehicle accident which occurred on September 29, 2013. A true and correct copy of the Coroner's Certificate of Death is attached hereto and marked as Exhibit "A." 3. This motor vehicle accident happened on Braddock Road heading north on Fairfax County Parkway in Fairfax, Virginia. A true and correct copy of the Police Accident Report is attached hereto as Exhibit "B." 4115.'75 Pp V�Tf L►t�c I3 4. On August 29, 2014, the Cumberland County Office of the Register of Wills issued Letters of Administration to Bharath Kasireddy for the Estate of Baby -Girl Dulam-Kasireddy. A copy of the Certificate of Grant of Letters is attached hereto and marked as Exhibit "C." 5. At the time of the accident, the striking vehicle was owned, driven and insured by Abraham Aragon who also died in the accident and insured by an automobile policy no. 5345V 606818, issued by Nationwide Property & Casualty Insurance Company, which carried liability limits of $5o,000 per person and $100,000 per each occurrence. There is no stacking of the liability limits under Virginia law of the other vehicles owned and insured on this policy. Attached hereto and marked as Exhibit "D" is a true and correct copy of the Declaration Page of the Nationwide Policy. 6. Bharath Kasireddy was the driver and Mrudula Dulam was the passenger in the vehicle struck by Abraham Aragon. Both Mr. Kasireddy and Ms. Dulam suffered injuries. The force of the impact resulted in severe force to the mother's abdomen which in turn caused extensive trauma and fetal distress necessitating an emergency C -Section; however, the trauma was such that the baby did not survive. The cause of death was "placental abruption." See Exhibit "E." 7. At the time of the September 29, 2013 motor vehicle accident, the 2002 Toyota Avalon 1 was owned and operated by Bharath Kasireddy and was insured by Travco Insurance Company. The insurance policy provided for Underinsured Motorist Benefits of $100,000 per person and $300,000 per accident. 8. Travco Insurance Company filed an Uncontested Petition to Settle Wrongful Death and Survival Action to resolve the claim of the Underinsured Motorist Benefits related to the death of Baby -Girl Dulam-Kasireddy for the sum of $ioo,000, the policy limits. The Honorable Judge Thomas A. Placey entered an Order on May 7, 2014 settling the Uninsured Motorist Benefits for Baby-Girl Dulam-Kasireddy at Docket No. CV-14-2748. A true and correct copy of the Order is attached as Exhibit "F." 9. A search was conducted of assets of the deceased Abraham Aragon to determine whether there are any owned assets in either Abraham Aragon's name which would constitute potential assets for collection beyond the insurance policy limits of Nationwide. It appears that Abraham Aragon had no appreciable or collectible assets and died intestate. 10. Nationwide Property & Casualty Insurance Company has agreed to pay the entire $100,000 limits to the three claimants, Bharath Kasireddy (father), Mrudula Dulam (mother) and Baby-Girl Dulam-Kasireddy in equal amounts of $33,333.33. 11. The Estate of Baby-Girl Dulam-Kasireddy would therefore receive $33,333.33. 12. Petitioner Bharath Kasireddy is not represented by counsel but understands his right to counsel and is satisfied that he has a complete understanding of the claims and any future consequences, and elects to proceed pro se. 13. Nationwide Property & Casualty Insurance Company retained the undersigned attorney to prepare and file this petition seeking approval of the wrongful death and survival actions. 14. Petitioner seeks the Court's approval of this settlement and the distribution of settlement proceeds as set forth herein, and a proposed Order attached hereto. 15. The following settlement is proposed: $33,333.33 for wrongful death and $o for survival action. 16. The proposed settlement is reasonable for the following reasons: a. The available policy limits are being exhausted with the settlement and a portion pro rata among the claimants. b. The Petitioners are of the opinion that the proposed settlement is reasonable given that the available auto liability coverage is being paid in full; c. The undersigned counsel is not requesting expenses to be reimbursed. d. The expenses for the Estate have also been paid by Nationwide Property & Casualty Insurance Company, and those expenses are not being sought for reimbursement; e. There are no unpaid medical expenses. 17. Petitioners believe that net proceeds of settlement should be allocated in their entirety to the wrongful death action and not the survival action in view of the compromises amount of settlement, the lack of conscience pain and suffering, and the general policy of law in favor of the wrongful death claim to the extent of affording it full priority over the survival action as set forth in Wringler Estate, 29 Fiduc. Rep. 499 (1979). 18. Pursuant to 42 Pa. C.S. §83o1, the beneficiaries of a wrongful death action and their respective interests are as follows: a. Bharath Kasireddy and Mrudula Dulam, parents of the decedent, Baby-Girl Dulam-Kasireddy. b. There are no other liens or claims against the proceeds of these actions or against the decedent's Estate. c. The parties have agreed to the terms of a written release, a copy of which is attached hereto marked as Exhibit "G." d. Bharath Kasireddy has executed an Affidavit attached hereto and marked as Exhibit "H" attesting to the fact that he agrees with the terms of the settlement and that there are no outstanding bills, expenses, or liens of any other claims against the Estate. WHEREFORE, Petitioners respectfully request that: a. Bharath Kasireddy, as Administrator of the Estate of Baby -Girl Dulam-Kasireddy, be authorized to enter into a settlement agreement set forth above; b. Bharath Kasireddy, as Administrator of the Estate of Baby -Girl Dulam-Kasireddy, be authorized to execute an appropriate Release in favor of Abraham Aragon and Nationwide Property & Casualty Insurance Company; c. An Order be entered directing the payment of $33,333.33 be paid to the Estate of Baby -Girl Dulam-Kasireddy, and then distributed to Bharath Kasireddy and Mrudula Dulam. Bv: Dated: V CA0`1- -e._ ' , 2014 Respectfully submitted, THOMAS, THOMAS & HAFER, LLP n F. Yaninel „Esquire TTORNEY I.D. No. 55741 305 North Front Street P.O. Box 999 Harrisburg, PA 17108-0999 (717) 441-3952 Attorneys for Nationwide Property & Casualty Insurance Company and the Estate of Baby - Girl Dulam-Kasireddy,. Deceased.. EXHIBIT A COMMONWEALTH OF VIRGINIA - CERTIFICATE OF DEATH DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS - RICHMOND COPY AREGtSTRATIOtt FOR DIVISION OF VITAL RECORDS AEA NUMBER • f � TETTTtF1CATE NIJMBfA / (O 5 MEDICAL EXAMINER'S CERTIFICATE STATE -, 2: E% melsIwNlr DECEOFJTT 1.FULLNAME • ( ) (middle) IuMq OFDECFDENT Baby Girl Dulam-Kasireddy ❑ KI • 3. DATE OF (mo.) (day) (Kele DEATH 4. AGE IF UNDER 1 YEAR I IF UNDER 1 DAY mckttna T elys hOWI minutes ' ' 5 5' BIRTH F (mo.) (day) (pat) (pat)Even `est. 29 2013 0. WAS 1H U.S. T y.' M/ ARMED TonCEs?❑ ®1 Se . tember 29, 2013 0153' 8, COUNTY OF DEATH (11 Itelopendant dry. lee ws ENn8) PLACE OF DEATH 7. NAME OF HOSPITAL OR INSTITUTION OF DEATH (if none. so Hate) 1 Out Pat. • m Inpallo I DOA Emer Rm INOVA Fairfax Hospital 0 - 0 airfax 9. CITY OR TOWN OF DEATH Made dly or teen 8mka? Falls Church i ® 10. STREET ADDRESSOR RT. N0, OF PUCE OF DEATH 3300 Gallows Road USUAL OF DECEDENT 11. STATE (0R FOREIGN COUNTRY) OF DECEDENTS RESIDENCE Virginia • 12. COUNTY OF DECEDENTS RESIDENCE (U tndep4ttdont dly+leave btankl IJP CODL• 1?. C31Y OR TOWN OF RESIDENCE fmMo dry er town itmks7 Lorton * ID ® 14. STREET ADDRESS OR nr. NO. OF IIESIDENCE r. NO. OF• 7339 Ardglass Drive 122079 PERSONAL' DATA OF DECEDENT 15. NAME OF DECEDENTS FATHER Bharath Kasireddy 16. MAIDEN NAME OF DECEDENTS MOTHER Mrudtlla Dulam 17. RACE OF DECEDENT 18.0F HISPANIC 081 INT If yes. specify Cuban, Mexican. Puede RIM. No. El 10 0 ye, 19. EDUCATION (Spodry only Nghos1 grade comploled) • - 0 or 6�1 ' Asian FJomaotarylSaeondary(o•12y C511apa11-1 20. CITIZEN OF WHAT COUNTRY U.S.A. 21. BIRTHPLACE (state or mums)) Virginia 22. NEVER MAMIED %.N DIV CEO a MARRIED❑ mom:. ❑ pl dl reior 6Qvo bIIDrEO, NAME OF SPOUSE • 24. SOCIAL SECURITY NUMBER 25. USUAL OR LAST OCCUPATION . 26.10ND OF BUSINESS OR INDUSTRY 27. INFORMANT • On SOURCE OF INFY3fMATION Mrudula Dulam - Mother CAUSE OF DEATH 28. PART t FnUstalonly ono t too diseasess on each , INudes, or Me. camy8catiorts ittai caused the doalh. D* ria enia Uro rnodo of dyNg, aunt u eatdiae orrtsp ntary etteaI, stwek, 0r taMt taYura• caw -'�LA-.CeNTaI- i10iLurrto IMMEDIATE WTEAYAL 0E1 ON tT DTH AND EA 0vr5 TO MEDICAL EXAMINER: cone/don rreeusulting In death) of -� OUET0 (ORASAGONSEOUF E 0Fj: .• • IeaMn ) Coon 4ele and don S britte etly lit wnditons,11 ury� b Immediate cacao. Eisler UNDEALYIN( DUE TO (OR AS A CONBEOUENCE OF): CAUSE (placate or N)ury that M6leled resulOng M dao) LAST - (gem 25) end give al .n F PART 11. Other algdfeant candalons pMulbutIng to OHO but nM mulling In 1110 underlyln9 cause given In Part L 2111. AUTOPSY? 999 00, ' 3 eepla to funeral dbedor es soon as Inquiry. et AUTHORIZED DY: 0 Da . _ .. Pile aAer iv 4 28b. IF FEMALE, WAS THERE A PREGNANCY •IN PASTS MONTHS? yes mI% udutorm0 280 IF EXTERNAL CAUSE, IT WAS 10 Ceur6A' AWHrarotrnuo❑ ldcws or DEATH 214, DESCRIBE HOW INJURY RELATINO TO DEATH OCCUnII•o ,AIV Ti. MOTOti V tr' (4 lc s�3 CR.,4,s N NOTE 1f "PendM9" must be ktecled, nosy rests 20,. TIME OF INJURY (mo.) (day) hear) /� yA.m�/(' n /, W � � •• P)( ! 4 GI " t 201. INJURY OCCURRED . a wc,k ❑ al work e ❑ 2663. PUCE OF INJURY lhomr, (anis, t 28l1, (dry 0r town) (7081 ) (slate) /,(acbry auesL otAc{�osCldQ., e/taT) 1 V 4� Qv 'J ' 1(.0 3'1 r i �L'� 1'1 f�.x A Iran of Mal dedsfon es soon as possible. 281. I CERTIFY Mal I leek charged the remains described above, viawad Ike body, made Inquiry end In my opinion doslh tea ed et of eboul' n t IAM( kelirt n: J NATURAL CAUSES ❑ ACCIDENT r LE_ MICIDE ❑ UNDETERMINED 0 PENDING • _ ` y) 1 4 Ltil4i) t& )•�'%% i11 _SUICIDE _ SIG rU1TUREP_, • _ GATE SIGN 0; A!�� 1 ©r LGA -!3 , ' NAME OF M OICA1) .M FA (Type .r) ��I Am ci-I OF M(:Dlf NEtI 1 V /Nf. G IveYr f N I t7 ala Vel (V � 1 1/ A. FUNERAL . DIRECTOR. _- 29.. BURIAL REMOVAL CREMATION . 30. PLACE (name of et1Glary or amatory) (Ary oscnunry) owe) OF BURIAL, ,. ,a . .. '..... .. •- REMOVAL. ETC."Futtere Choices of'..Chantill y ,. Q ❑ � �] .. -Chantilly-- Vir, itiin . 3t. '"•' aidire�t�rappwnl633674tmg,�, •.;..to-) NAME 0 EANDNGiUI Funeral Choices 61 1.:banti1ly. er.er-,a. /. ADDRESS:14522L Lee Rd. 8Chantilly,VA 20151 REGISTRAR 32. signature of rOglo.Fan DATE RECORD �I/"/l ..t DATE � j ,/ - •�J -'_ RESERVED FOR REGISTRAR'S USE ... • This is to,,.vertiifyrthat this is a true and correct reproduction of the original record tiled with the .FA:IRFAX-COUNTY HEALTH DEPARTMENT, FAIRFAX VIRGINIA. • 2013 DEPUTY REGXTRAR VOID IF ALTERED OR DOES NOT BEAR IMPR +SSED SEAL Generated by CamScanner from intsig.com EXHIBIT B 1 Rightfax C2-2 FAX 11/8/2013 1:08:23 PM PAGE 1/010 Fax Server To: Crystal Company: Fax: 8554916742 Phone: From: JEHARTMA@travelers.com Fax: Phone: E-mail: NOTES: Police Report - Claim Number 073050 GA This communication, including attachments, is confidential, may be subject to legal privileges, and is intended for the sole use of the addressee. Any use, duplication, disclosure or dissemination of this communication, other than by the addressee, is prohibited. If you have received this communication in error, please notify the sender immediately and delete or destroy this communication and all copies Date and time of transmission: Friday, November 08, 2013 1:08:04 PM Number of pages including this cover sheet: 10 Rightfax C2-2 11/8/2013 1:08:23 PM PAGE 2/010 Fax Server Title: ACCIDENT REPORT_20132720025 DRAFT Attach: 8AE006AA-8A15-44CA-9E9B-B0B8F561B005.pdf Rightfax C2-2 'Revised Report •••••::::) CRASH cum DayofVetc Date 09 29 i 2013 SUN dty or Town Name <;:t City of Town of Location of Crash (rotle/street) RT286 FAIRFAX COUNT PW Al intersection Wth or 500 1%1 Mlles 11/8/2013 1:08:23 PM PAGE 3/010 Fax Server Commonwealth of Virginia. Department of Motor Vehicles Police Crash Report MIUTARYTnre (24hr dock) 0140 GPS Lat. 00.0000000000000 County of Crash FAIRFAX COUNTY 1111 III 1 II 0 7 0 7 A GPS Long • 00.0000000000000 • • Landmarks at Scene NONE Railroad Crossing ID no. (If within 150 ft.) N S EW Location of Crash (route/stree4) Feet :Ai:: •••• RT620 BRADDOCK RD FR303P (Rev 7/07) Page 1 of 4 • CMV Use Local Case Mater 2013-2720025 Nile Maker Klaiber Nunber of Vehicles 002 ARAGON, ABRAHAM Address (Street and Klaiber) 11227 SOLDIERS RIDGE CIR STE 304 Apt. 304 City MANASSAS State :21p VA 20109 Birth Dale O316 safety Eculp, Used 2 Summons Issued As Restlt d Crash VHICLE Vehicle Osinees Name (Last, Rrst, Midde) Same as Driver 's Drivers license Nunter 1969 1A69647194 ittMag tfected bale oftlealh 3 1 09 29 0013 2 2 DRIVER Driver Red Scene $ Driver's Nm(Last First, Middle) KAS I REDDY, BHARATH Gen Address (Street and Number) .:416 MEADOW DR CAMP HILL thbifvers License Number Date 08 17 1978 28755710 5i:5if • • Artaaj••ii•tlierreir- -bat 6ef 3 1 1Suiinons Offenses Charged to Diver $ Issued As $ Remit of Crash r• State rt CDL VA injury Typ3 081'rensporl .i • Address (Street and Minter) City State ZP Vehicle Year Vehide Mike 1 9 9 3 MAZDA Vehicle Fiat Umber Vehicle Mock! MX3 iStde WUM1911 • VIN ,JM1EC4326P0219038 ilsabled CMV Tuned Approximate Repair Cost ••••••73 g poo Oversize Cargo sttI- !time of Insurance Company (not awni) NATIONWIDE INSURANCE Speed Before Crash 50 r=1 igi=t4,ga,riticke) Override Utderride SaedlimIt: Maximum Safe Swa! ALL Passengem Age Count 50 50 8 847 18-21 :2I • Position Safety I Airbag Ejected Iri/n • de s EitiP s Used • • V Ek1S Transport Injury fi;Pe Birthcktte • State 71P PA i17011 Stele IX. ?",ttiL PA Injury TWO' "EILISfrenip'Oit 2 $•••• VEHICLE VeHdeamer's Mime (Iasi, First, Midde) Same as Driver •:*:: Address (Street and Number) Qty State 21P $VehicleYear $ Vehicle Make Vehicle Maki 2 0 0 2 rTOYOTA AVALON VeH de Plate timber GZS6039 ii4T1BF28872U254854 • meof Insurance Corrpany (not aged) rTRAVELERS INSURANCE Stale P Osatied CMV Towed Approximate Repair Cost 1 0 000 Oversize Cargo spill Before Crash Speed Limit Maximum Safe Speed under 50 50 50 PASSENGER (only if injured or killed) •Nano1 Injured (Last, First, Midde) M RUDU LA Position Safety Airbag $ Ejected : In/ar r Equip .Velcle3 Used, 1 1 • •- • • • Override Urderride AIL. Passengers Agebouni over 8-17 1821 21 01 Injury Type 2 BAS Transport Date of Death Balhthte Gender (.r?: 04 02f:1984 of Injured (Last, Firsi, Midde) EMS Transprxt Date of Death of injured (Last, First, Midde) EMS Tramped :Date of Death Peeltlai tWOn Vel-icte $ Safety Equi Airbag Ejected Injury 1ype Birthdate Rankin In/On Vehicle :•'s safety sEopi Us ected Type Birthdate t• $ Gender f:::: Wale of In)umcf (Last, Rrst, Wide) .. Position i .Gafi. .: , Eciti-i; $. Airbag $ Ejected $ VeHcle 3Used.. • Codes ..• • 1 2 3 a 4 7 POSITION INION VEHICLE 1. Driver 2-6. Passengers 7. Cargo Area 8. Riding/Hanging On Outside 9-98. All Other Passengers EM5 Tramped Injury fype Birthdate bated Death SAFETY EQUIPMENT USED 1. Lap Bell Only 2. Shoulder Belt Only 3. Lap and Shoulder Belt 4. Child Restraint 5. Helmet 6. Other 7. Booster Seat 8. No Restraint Used 9. Not Applicable • Gender Nacre of Injured (Last, tirst, MIcicie) * IntOn $ Equip A 41,:f Position safety Vehicle $ Used EJECTED FROM VEHICLE 1. Not Ejected 2. Partially Ejected 3. Totally Ejected AIRBAG 1. Deployed - Front 2. Not Deployed 3. Unavallable/Not Applicable 4. Keyed Off 5. Unknown 6. Deployed - Side 7. Deployed - Other (Knee, Air Belt, etc.) B. Deployed - Combination SUMMONS ISSUED AS A RESULT OF CRASH 1. Yes 2. No 3. Pending Injury Type EM5 fransprit?.bate of Death .S.*:?•;; Birihcbte Gender INJURY TYPE 1. Dead Before Report Made 2. Visible Signs of Injury, as Bleeding Wound or Distorted Member or Had to be Carried Rom Scene. 3. Other Visible Injury, as Bruises, Abrasions, Swelling, Limping, etc. 4. No Visible Injury, But Complaint of Pain, or Momentary Unconsciousness. 6. No Injury (driver only) Officer's Name (last, First, Middle) KEEVILL, E. Badge or Code Number 300644 Agency/Departrmnt Name and Code FAIRFAX COUNTY POLICE Reviewing Officer Report File Dale i::09 29 2013 10 110201320322 PM [Eastern Standard Time] OHLEWAPP1040 554916742 Rlghtfax C2-2 02.40 QUINLC1 Rightfax C2-2 11/8/2013 1:08:23 PM PAGE 4/010 Fax Server Officer Initials EIKBadge 0 aQ.0.56i4_ Commonwealth of. Virginia. Department of Motor Vehicles I II II 11 II I 11111 FR300P (Rev 7/07) Revised Report :!:.. : Police Crash Report 11111 Page 2 of 4 CRASH Dash X'•:: 1::i; ?V rf NOLITARYTime (24hr dock) iCcunty of Crash i'....:::j atY of local ease hirriaer f: ii Date 1 09 29 2013. 0140 !. FAIRFAX COUNTY .:::::) Tovm d :% 2013-2720025 DRIVER INFORMATION 2 , . ?Ai,: 1.1331moper Adion 2.Exceeded,eedtJnfl •-'s 3. Exceeded Safe Speed But Not Sped Lid! 4, Ovataldng Cn Hill 5. Overtaking On Cuve •:.••• 6. Ckertaldng at Intersection •.• 7. Impmper Passing of School Bus • B. Cutting In 9. Other Improper Passing •;:;•; 10. Wrong Side of Aced Nat Overtaldng 11. Did Not Kw° Rild-crtWay " 12. Foil ovA rg Too Close 13. Fdl to Signal or Improper Signal 14. Improper Turn -With RI91it Ttrn 15. Inprcper Tum - Cut Corner on Left Tun 16. Inproper Tum Fran Wrong Lae 17. Other Improper Turn 18. Inprcper Baddng 19. Inproper Stot Rom Parked Post 6 cn 20. Disregarded OH cer or Flagwr 21. Disregarded IkaffIc Signal 22. F3&egaittedop or Yield Sign 23. Diver Dislraction 24. Failed to Sop at Through high way- No Sgn 25. DrivelhninjhWorkZene 26. Felled to Set Cut Rwes or Rags 27. Fail to Dim Headights 28. Diving Withod Lights 29. Improper Parking Location 30. Avoiding Pedestdan 31. Avong Other Vehide 32. Avoiding Animal Dovided Off Ifiliway . 34. Ht and Rim ' 35. Car Ran Away- No Driver 36. Blinded by HeadligMs 37. Other 35. Avoiding Ctiect In Roadway 39. String Police "2‘ 40. Fail to Maintain Proper Control 41. Improper Passing ''•• 42. Improper cr Unsafe Lane Change 43. Over Correction 1. Nat Obscued 2. Rein Snow, etc. on Windshidd 3. Windshield Otherwise Obscured 4. Vision Obscured by Load On Vehicle & Trees, Dom etc. 6. Building 7. Embodiment & Signor Sgnhoard 9. HlIcrest 1D, Parted Veldde(s) 11. Moving Vehicle(s) 12. Sin or HeadIgh1 Dam 13. Other 14. Blird Spot 15. SmolaiDust 16. Stepped Velide(s) 1. Looking at Roadside I rtcldent 2. Diver Fatigue 3. Loddng at Scenery 4. Passenger(s) 5. Rado/CD, etc. 6. Cell Fiona 7. Eyes Not on Road 8. Daydreaming 9. EdincyDriridng 10. usting Vehicle Controls 11. Other 12. Notion Device 1. Had Nal Been Clinking 2. Dlridng- Obviously Diu* 3. Drinking -Ability Inpalred 4.Crinidng -Ability Not Inpaired 5. Dinldng Knoell Whether Impaired 6. Unlacwn VEHICLE INFORMATION •••.: .: I . • 1. GIng Straight Ahead 2. Maidng Rijd Tun 3. Making Left 'Man 4. r�Tn 5. Slowing or Stopping 6. Merging Irdo Traffic Lsne 7. Starting From Parked Position 8. Sopped in Traffic Lane 9. Ran CH Road - Right 10. Ran Off Road - Left 11. Parked 12. BacIdng 11 Passing 14. Clanging lanes 15. Other 16, Erierirg Street Rom Parking Lot 1. No Defects 2. Eyesight Defective 3. Hearing Defective 4.Other Body Defects 5. illness 6. Fatigued 7. Apparently Asleep & Otter 9. Unknown 1.Eliced 2. Breath 3. Refused 4. NoTest 1. Yes hb 3. Unimomi ---------------- 001WWMPL,.. 1. Before AFplication of Brakes 2. After Application of Brakes a Defame/1d After application of Brakes 4. No Visible Sidd MarWTI re Mark 1. Passenger car 2. Taxi( Pick-tpfPasserger Truck 3. Van 4 Tru:k- Single Unit Truck (2 -Ades) 7. Motor Home, Recreatiorel Vehicle & Special Vehicle • Oversized VehicidEarthmover/Road Equipment 9. Bicycle 10. Moped 11. Motorcycle 12. Emergercy Vehicle (Regardless d Vehicle TyFe) 13. BUS • SCII3DI Bus 14. Bus- City Transit Bus/Privately Chemed Church 13US 15. Bus- Commercial Bus 16. Other (Semler, Gomart, Hearse, Roam:bile, Golf Cart, etc. 18. Spedal Vehlde- Farm Machinery 19. Spedal Vehicle- XIV 21. Sped al Vehicle- low-SFeed Vehicle 22. Truck - Sport WI ity Vehicle (SUV) 23. Truck- Sngle Unit Trudi (3 Axles or More) 25.Tmck-1.0,w.0.01.A.n.Now.lko 3. 11 2 • 1. Marvin 2. No damage 3. Overturned 4. Mdor ../ 5. Undercarriay 6. Tattled 7. Fire 8. Other 1. No Defects 2. Lights Defective 3. Brakes Defective 4, Steering Defer:bye 5. Puy:tuft/Blowout 6. Worn or SIck11res 7. Motor Treble & Chins In Use 9. Other 10. VeHde Altered 11. Mirrors Defective 12. Paver Train Ceective 13. Suspension Defective 14. WindowsM ndshield Defective 15. Wirers Cdedive 16. Wheels Defective 17. Exhaust System ••:i. 1. No Special Function 2. Tad 3. School Bus (Public a Private) .; 4. Transit Bus 5. Interdty [kis • 6. Charter Bus 7. Otter Bus 9. Pdice 10. Ambulance 11. Fire Truck 12. Toe/Truck 13. Maintenance 14, Unlotown a -1. Yes Z No 10 111812013 2:0822 PM (Eastern Standard Time] OHLEWAPP1040 554916742 FtIghtfax C2-2 02-40 QUINLC1 RightfaX C2-2 ,Otticer Initials EIK Badge ft 300644 Revised Report CRASH 11/8/2013 1:08:23 PM PAGE 5/010 Commonwealth of Virginia. Department of Motor Vehicle: Police Crash Report Fax Server ft UI II 11 FR3°OP (Rev 7/07) Paga 3 of 4 0 7 0 7 C Oashv'e7 Date 09 i292013 MILITARYTine(24 hr dock) 1Courdy of Crash 0140 FAIRFAX COUNTY 1.01 Roadmay -2. Shoulder 3. Medan 4.1loadskie 6. Separator 7, In Padang tale or Zone OH Roadway, Location Unknown f;;;;;;:• 9. tatsidengtt-of-Way ... 1. No Adrerse Candid cn (Ctear/Cid.rdy) aF C..> filst 5. Rain Sleet/Kali a Smote/Dust 9 Other 10. Blowing Smut Sok art or Snow 11. Severe Crosswinds 1. Dawn DaY4it 3..Dask <2') • *Darkness 7 Road Ugded 5. Darimess - Road Nct Lighted 1. Darkness - Unknown Road Lighting littikramt 1. Yes World ng 2. Yes Working and Obscured 3. Yes- Not Woridng 4. Yes • Net Wcddng ord Obsctred 5. Yes- lasing 6. Nu Trak lc Co ntrd Device Present (:) 1. No Traffic Control 2. Miser or Ragser 3. Traffic Signal 4, Stop Sign 5. Sow or Warning gn 6. Traffic Lanes Marked 7. No Passing Unas B. Yield Sign 9. One Way Road or Street 10. Railroad 0'os5kWIh Markings and 9 gns 11. Railroad Crossing Wth Sire's 12. Ftallrced Crossing Wth Gate and Signals •:::*1) 13. Other 14, Pedestrian Crosswalk 15. Redrced Speed Sdnol Zone 16. Reduced Speed - Work Zone 17, Highway Safety Corridor kDatyd Town d Case 12013-2720025 CRASH INFORMATION • ••••,••••••,••,, •,•.• ••• ••.•••....., • • Atij) 1. Straight - Level 2. Curve - Level ::> 3. Grath - Straight 4. Gracb anve 5.141I nest - St rallit 6. Ittcrest - Orme - Straight • a 9p- Clive 9. Other 10. OnlOtt Rang ethn C7 • 1. ty 2.W 3. Showy C:2> 4.1cy 5. Muddy • 6. 00/Cther Fluids 7.0(1r B. Natural Delxls • 9. Water (Stand rg, Mavirg) Sush 11. Sand, L1rL Gavel 1. Concrete 2. BlacIdop, Asphalt, fltuninous 3. Brick or Block 4. Slag, Gravel, Stone 5. Cirt 6. Other 14134440/M1P1100:i5.*1:fliii:IVA:1:*i. 1. Two -Way, NA Divided 2. Two -Way, Divided Unprdected Median 2.Ty Divichd, Positive Medan Barrier 4 OneWay, Nd Divided 5. Unkrown 1. No Detects 2. Hdes, Ruts, Bumps 3. Soft a Law Shaul der 4.UrsJerIair 5. Loose Material 6. Restricted Width 7. Slick Paverned B. Roadway Obstruded 9. Other 10. Edge Pavenerd Drop 00 • Interchange Area: 1. Maln1.1re Rcedway AcceleratlailDeceleratIcn Lanes 3. Gore Area (Be(ween Rang and Highway Edgellnes) 4. Collector/Distributer Road 5. On Ertrance/Edl Ramp 6.1nlersectIon at end of Rang 7. cher I °cab cri not listed &eve .within an Interchange area (median, shoulder and roadside) Intersection Area: B. NarldersectIon 9. Mtfln Intersection 16. I ntersecticri-Related - Whin 150 e.*::::.•; 11. IntersectiartRelated • Oils1de150' Other Location: 12. Crossover Related 13. Driveway, Alley -Access - Related 14, Railway Grade flossing 15. Other Crossing (Crossings for Bikes, Shod, etc.) 1. Not at Intersection 2.1Nvo Approaches 3. Three Approaches 4, Four AFproaches 5. Fiveguint, or more 6. Roundabout . • • - art, 4 1. WithLavrErlorcenert a With No Law Enforcenrnt a No Worked Present cat • 1. Advance Warning Area 2. Transition Area 3• . Activity kea 4 Termination Area 1. late Closure 2. Lane Stift/Crossover 3. Work ai Shoulder or Median 4. internitbant sr Moving Work 5. Other ............................. 1. Yes 2. Yes- Wth9chod Activity 1. Rear End 2. Angle 3. Head On 4 Sidendpe- Sang Direction 5. Sideswipe - Opposite Cirection • 6. Fixed (lied In Road 7. Train a Non -Collision 9. Fixed Object - Ctf road 10. Deer 11. Other Arirnal 12. Pedestrian 13, Bicyclist 14. !Motorcyclist • 15. Backed Into 16. Ober z a E 3. a 2 0. 9 g Rightfax C2-2 Officer Initials EIK Badge # 300644 Revised Report .' CRASH 11/8/2013 1:08:23 PM PAGE 6/010 Coirmonweaflh of Virginia. Department of Motor Vehides Police Crash Report Fax Server II 0 X11111 II11111 Page 4R300PPof (Re47/07) Crash %:.. ... Date 09 29 22013 F0l In Impact Area(s). _ Initial Impact. 12 12 Veh Dir of Travel - N/SIE/W liKto FIII In Impact Area(s). Initial Impact. 12 12 1 2 4 5 Veh Dlr of Travel:, N/SiE/W MILITARYTtrre(24hrdock) ; County ofCrash :. City • Local Case Number 0140 1FAIRFAX COUNTY •••• . 2013-2720025 CRASH DIAGRAM 4 ROUTE 266 FAIRFAX PUNT' PIiVdY Cts. Awe, V2 Vt .13:01;1133-4-- R', 620 BRADDOCK RR?D} Indicate North by Arrow DAMAGE TO PROPERTY OTHER THAN VEHICLES Apprc Repair Cosi Di ject Struck (Tree, Fence, eI)Propedy Owners Name (Last, first,, Mdde) ,cRASJiP S.RIPTi0N FIII In Impact Area(s). Initial Impact. 12 10 •:'.,:i Imo•,. `. � 12. 3 7 :. 5 Veh Dir of Travel - NISIE W FIII In Impact Area(s). Initial Impact. 12 2 3 4 ..' S Veh Dir of Travel - N/S/EiW Address (Street and Number) VDOT Property V2 WAS SOUTH BOUND ON RT286 APPROACHING RT 620. V1 WAS NORTH BOUND IN THE SOUTH BOUND LANES AND STRUCK V2 HEAD ON. CRASH EVENTS `tf tiftf;r <<<"t1r Eiia 1 s 20 Ve�ttae:....FtEsl:ivsr• g t • . 'SetOil tired z:El3ffd'.IireEd'. tussl:i;uhiit::=?A'kisf:Hairiitut: Rightfax C2-2 11/8/2013 1:08:23 PM PAGE 7/010 Fax Server F.`` UNAP Rs' V U'NAPPR `:' `. ` ;? ,JNAS'R<)V Accident Supplement 2013-2720025 Supplement type: ASSISTING OFFICER NARRATIVE I was the first unit to arrive onscene of the accident at the above location. Upon my arrival I noted a blue vehicle, which appeared to be facing in a northern direction in the south lanes of the Fairfax County Parkway positioned in the left lane. There was a gold vehicle that was facing a southern direction on the Fairfax County Parkway. It appeared as if both vehicles collided head on into each other. There were several people in the grassy area to the right of the shoulder, one was a passenger in the gold vehicle and she is 6 months pregnant. She was going in and out of consciousness while several people to include her husband who was in the vehicle with her continued speaking to her to keep her conscious. I spoke to two witnesses. Mr. Cooper advised he was traveling south on the Fairfax County Parkway in the left lane, he observed the blue vehicle traveling north in the south left lane of the Fairfax County Parkway. Mr. Cooper veered to the left to avoid him striking his vehicle when he saw the blue vehicle crash into the gold vehicle that was traveling south in the left south lane. I spoke to Mr. Worthen who advised me that he was traveling in the right south lane of the Fairfax County Parkway when he observed a blue vehicle driving in the left south lane going in a northern direction collide with a gold vehicle head on. Mr. Worthen veered to the right to avoid the collision. I spoke to several other people at the scene, none of which witnessed the accident. I assisted in traffic control until the road was reopened. Nothing further done by this unit. 6 Z_ 5 a .0 9 tV 8 qX 1O 0 0 a a 0 O D V 2 CO CO P. • Signhere SCHMITT, LESLIE G FAIRFAX COUNTY POLICE DEPARTMENT 9/29/13 0 officers Rank and Name Department Date of report Printed at:10/30/2013 17:01 Page: 1S Rightfax C2-2 11/8/2013 1:08:23 PM PAGE 8/010 Fax Server ,\r :) ITROVE :r:•.cO Pi) ;r r ••��:' :\ :r;rROV, �\ ` +N ".::? •' 'W} ) ;'tN ;"r�r ...... ..'�r�.. .. ..\$. ...... .?�:�_. ..gin\J.. `'...... .1 ��.....�5, v .': �. .'�;�... ....�\. .:: �: �;�... .. .\\t nt .. ♦.':' Accident Supplement 2013-2720025 Supplement type:FILE 41 NUMBER OF PEOPLE KILLED IN CRASH: 1 1. NAME OF PERSON KILLED: ABRAHAM ARAGON 2. ADDRESS OF PERSON KILLED: 11227 SOLDIERS RIDGE CIRCLE,MANASSAS,VA 3. SEX OF PERSON KILLED: Male 4. RACE OF PERSON KILLED: Hispanic 5. DOB AND AGE OF PERSON KILLED: 03/16/1969, 44 YOA 6. WHETHER PERSON KILLED WAS A: Driver 7. WHETHER PERSON KILLED WAS A MEMBER OF THE ARMED FORCES, IF SO, BRANCH: N/A 8. DATE, TIME AND PLACE OF DEATH OF EACH VICTIM: 9/29/13, 01:40 AM, RT286 FAIRFAX CO PW 500 FT NORTH OF RT620 BRADDOCK RD 9. DATE AND TIME ACCIDENT OCCURRED: 09/29/2013, 1:40 AM 10. ROUTE NUMBER OR STREET NAME, DISTANCE AND DIRECTION FROM NEAREST INTERSECTING ROUTE OR STREET: RT286 FAIRFAX CO PW 500 FT NORTH OF RT620 BRADDOCK RD 11. COUNTY OR CITY IN WHICH ACCIDENT OCCURRED: FAIRFAX 12. MAKE AND MODEL OF EACH VEHICLE INVOLVED IN THE FATAL CRASH: 1993 MAKE: MAZDA MODEL: MX3 FATAL VEHICLE: Yes [[VEH 2 YEAR - MAKE AND MODEL OF EACH VEHICT.F INVOLVED IN THE FATAL CRASH: VEHICLE 2 YEAR: ;10;0]] [[MAKE: ;11;0]] [[MODEL: ;11;0]] FATAL VEHICLE: Unk [[VEH 3 YEAR - MAKE AND MODEL OF EACH VEHICLE INVOLVED IN THE FATAL CRASH: VEHICLE 3 YEAR: ;10;0]] [[MAKE: ;11;0]] [[MODEL: ;11;0]] [[FATAL VEHICLE: ;1;1;Yes;No;Unk]] [[VEH 4 YEAR - MAKE AND MODEL OF EACH VEHICLE INVOLVED IN THE FATAL CRASH: VEHICLE 4 YEAR: ;10;0]] [[MAKE: ;11;0]] [[MODEL: ;11;0]] [[FATAL VEHICLE: ;1;1;Yes;No;Unk]] 13. TYPE OF ROAD SURFACE: Asphalt 14. NUMBER OF LANES OF HIGHWAY (DIVIDED OR NOT): 2 LANES \EACH RUNNING NORTH AND SOUTH DIVIDED BY A LARGE GRASS MEDIAN 15. NAME OF DRIVER OF VEHICLE WHICH DEATH OCCURRED IN: ABRAHAM ARAGON 16. NEXT OF KIN NOTIFIED. (EXPLAIN UNUSUAL CIRCUMSTANCES): Yes 17. ALCOHOL A FACTOR: Unk 18 VICTIM WEARING A SEATBELT: Yes 19. WAS THE MOTORCYCLE OPERATOR WEARING A HELMET: N/A 20. WAS THE MOTORCYCLE PASSENGER WEARING A HELMET: N/A 21. VIOLATION OF THE LAW, REGARDLESS OF ANY CHARGES PLACED: RECKLESS DRIVING 22. BRIEF DESCRIPTION OF FACTS: DECEDENT WAS NORTH BOUND IN THE SOUTH BOUND LANES OF RT286. HE STRUCK THE VICTIM VEHICLE HEAD ON AND DIED AT THE SCENE. 23. INVESTIGATING OFFICER EIN: 300644 24. CASE NUMBER 20132720025 Sign here KEEVILL, ELIZABETH IRENE FAIRFAX COUNTY POLICE DEPARTMENT 9/29/13 Officers Rank and Name Department Date of report Printed at: 10/30/2013 17:01 Page: 2S 10 111812013 2:08:22 PM [Eastern Standard Time] OHLEWAPP1040 554916742 Rightfax C2-2 02-40 QUINLCI Rightfax C2-2 11/8/2013 1:08:23 PM PAGE 9/010 Fax Server 3NisPPROv....iNA"PROWN;\ :;<ROVR UN ppROV `.'NApp Accident Supplement 2013-2720025 ::'NA ''R . ; is N &J_ •:\(,V D Supplement lype•ASSISTING .OFFICER NARRATIVE As I arrived onscene, I observed rescue personel attending to both patients onscene. I began to speak with a witness Ms. Ailleen Pace who stated that while she was driving she saw a small blue car drive across the grass and start driving the wrong direction in the Southbound lanes. I then began to reroute traffic to the Northbound lanes to get them moving again. A11 of Southbound was close off in the meantime. Once traffic was cleared from the scene. I obtained all the names of any Fire/Rescue Personel that worked on either vehicle or patient. I collected all vehicle info as well as witness info to pass along to CRU upon their arrival. Once CRU (Keevill) arrived onscene I passed along. any information that we obtained prior to her'arrival. We then moved on to the deceased body of the driver of the striking vehicle. We did not have a 100% identification so I assisted in taking fingerprints from the body. We then walked the accident scene. We did not notice any skid marks from either vehicle. We did observe 2 gouges in the pavement close to where the cars came to a rest. I took pictures of the vehicle and the scene with a digital Nikon D3200 camera. Those pictures were downloaded to a disk and a master copy was sent to the record room and a copy was sent to Det. Keevill. I then began my sketch of the accident scene. Once Det Keevill was finished with her pictures, I helped her mark the scene for measurements. We used the fog line on the right side of the road as our baseline and I pounded a shiner into the pavement as our reference point to measure from. Using the coordinate system I assisted Det. Keevill in measuring the scene. All measurements were transfered to my sketch. We then used a Vericom to obtain a drag factor for the road. We then responded to the Manassas Address listed as the residence for the deceased for a death notification. Once onscene we spoke with his wife and informed her of the news, she was given his possessions that he had on his person at the time of the accident. No further action was taken by this unit at this time. Sign here WALCZYK, CHRISTOPHER G FAIRFAX COUNTY POLICE DEPARTMENT 10/3/13 Officer's Rank and Name Department Date of report Printed at: 10/30/2013 17:01 Page: 3S 10 1118$2013 2:0822 PM (Eastern Standard Time] OHLEWAPP1040 55 Rightfax C2-2 11/8/2013 1:08:23 PM PAGE 10/010 Fax Server Accident Report 2013-2720025 Email Footer Sent at: 17:01 October 30, 2013 10 1118120132:0822 PM [Eastern Standard Time] OHLEWAPP1040 654916742 Rightfax C2-2 02-40 QUINLCI EXHIBIT C A PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Reset Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form: Decedent's Information Name: BABY GIRL DULAM-KASIREDDY File No: a/k/a: (Assigned by Register) a/k/a: a/k/a: Date of Death: September 29, 2013 Social Security No: Age at death: Decedent was domiciled at death in Cumberland County, Pennsylvania principal residence at 416 Meadow Drive, Camp Hill, PA 17011 Street address, Post Office and Zip Code Decedent died at INOVA Fairfax Hospital, 3300 Gallows Road Street address, Post Office and Zip Code Estimate of value of decedent's property at death: Wormlevsburg Borough City, Township or Borough Falls Church City, Township or Borough (State) with his/her last Cumberland County Fairfax County If domiciled in Pennsylvania. All personal property $ 1,000.00 If not domiciled in Pennsylvania. Personal property in Pennsylvania $ If not domiciled in Pennsylvania. Personal property in County $ Value of real estate in Pennsylvania. $ Real estate in Pennsylvania situated at: NONE TOTAL ESTIMATED VALUE. ... $ 1,000.00 VA State (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough Q A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated thereto dated County and Codicil(s) State relevant circumstances (e.g. renunciation, death of executor, etc.) Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and did not have a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. 0 NO EXCEPTIONS 0 EXCEPTIONS ✓� B. Petition for Grant of Letters of Administration (If applicable) c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durante absentia, durante minoritate If Administration, c.t,a. or d.b.n.c.t,a., enter date of Will in Section A above and complete list of heirs. Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. ® NO EXCEPTIONS 0 EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Name Relationship Address Bharath Kasireddy Father 416 Meadow Drive Camp Hill, PA 17011 Mrudula Dulam Mother 416 Meadow Drive Camp Hill. PA 17011 Form RW -02 rev. 10/11/2011 Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA ) } SS: COUNTY OF CUMBERLAND } Official Use Only Petitioner(s) Printed Name Petitioner(s) Printed Address Bharath Kasireddy 416 Meadow Drive, Camp Hill, PA 17011 The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as Personal Representative(s) of the Decedent, the Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this day of By: For the Register Date Date Date Date BOND Required; 0 YES 0 NO FEES: Letters $ 20.00 ( 2 ) Short Certificate(s) 10.00 ( 1 ) Renunciation(s). 5.00 ( ) Codicil(s). ( ) Affidavit(s) Bond. Commission Other Inventory 15.00 Inheritance Tax Return 15.00 Automation Fee. JCS Fee. 5.00 35.50 TOTAL $ 105.50 To the Register of Wills: Please enter my appearance by my signature below: Attorney nature: /MO Printed Name: Thomas F. Smida, Esquire Supreme Court ID Number: 37027 Firm Name: Address: Phone: Fax: Email: METTE, EVANS & WOODSIDE 3401 North Front Street PO Box 5950 Harrisburg, PA 17110-0950 (717) 232-5000 (717) 236-1816 tfsmida(a mette com DECREE OF THE REGISTER Estate of BABY GIRL DULAM-KASIREDDY a/k/a: File No: AND NOW, , , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration are hereby granted to Bharath Kasireddy in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. Register of Wills Form RW -02 rev. 10/11/2011 Page 2 of 2 EXHIBIT D 03281002245015 Nationwide® Leslie Tull Corrigan On Your Side 10755 A Ambassador Dr Manassas, VA 20109 Sign up for convenient, automatic bill payment with Nationwide Easy Pay. To learn more, ask your agent or log in to nationwide.com/easypay. What's enclosed Prepared on September 12, 2013 Page 1 of 2 Your Revised Policy Your bill is sent separately. Personal Auto Policy Policy Period: Sep 11, 2013 -Jan 19, 2014 Policy Number: 5345V 606818 Abraham Aragon PO Box 740 Manassas, VA 20113-0740 ✓ Declarations - These pages show your coverages under this policy. Carefully review these details and call Leslie Tull Corrigan at 703.361.0233 if you have questions or want to make changes. • General Information • Coverage Details • Your Total Policy Premium ✓ Insurance Documents - Please keep these documents for future reference. How to Contact Us Your Nationwide Agent Leslie Tull Corrigan 703.361.0233 Customer Service 1.877.669.6877 Internet Nationwide.com 24 -Hour Claims Reporting 1.800.421.3535 Hearing Impaired (TTY) 1.800.622.2421 Prepared on September 12, 2013 Page 2 of 2 Nationwide® Important Reminders from Nationwide On Your Side NOTES: The enclosed Declarations confirms changes made to your insurance coverage resulting in no change in premium. Please verify change(s). Sign up for convenient, automatic bill payment with Nationwide Easy Pay. To learn more, ask your agent or log in to nationwide.com/easypay. Manage your account, make a payment, check the status of a claim and receive your bill by email with online Account Access. Visit nationwide.com/manage - see how easy it can be. Nationwide thanks you for your business. Our first priority is to serve you, our Customer. Whether you have a claim, a question, a concern, or just need a convenient service, our On Your Side promise means we'll be there to serve your needs. Thank you for choosing Nationwide. We value your business. 03281002245024 Prepared on September 12, 2013 Page 1 of 4 Nationwide® Your Policy Declarations On Your Side Policyholder (Named Insured): Abraham Aragon PO Box 740 Manassas, VA 20113-0740 Personal Auto Policy Policy Period: Sep 11, 2013 -Jan 19, 2014 Policy Number: 5345V 606818 Keep these Declarations for your records. General Policy Information Issued: September 12, 2013 These Declarations are a part of the policy named above and identified by the policy number above. They supersede any Declarations issued earlier. Your policy provides the coverages and limits shown in the schedule of coverages. If more than one vehicle is insured, the Limits Of Liability will not be aggregated with similar coverage on another vehicle. Your policy complies with the motorists' financial responsibility laws of your state only for vehicles for which Property Damage and Bodily Injury Liability coverages are provided. Policy Period: September 11, 2013 -January 19, 2014 but only if the required premium for this period has been paid and only for six month renewal periods if renewal premiums have been paid as required. This policy is initially effective at (1) the time the application for insurance is completed, or (2) 12:01 a.m. on the first day of the policy period, whichever is later. Each renewal period begins and ends at 12:01 a.m. standard time at the address of the named insured stated herein. This policy expires at 12:01 a.m. at the address of the named insured stated herein. Your carrier is Nationwide Property And Casualty Insurance Company, NAIC #37877. IMPORTANT MESSAGES: 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. Changes Made to Your Policy Changed Deductible Credit Amount (Vanishing Deductible Feature) to $100. Comprehensive or Collision Deductible will be reduced by $100. • Effective September 11, 2013 • 2011 Toyo Rav4 • Added Lienholder Interest In the event of a covered loss, your Premium Summary and Other Charges 1993 Mazda Mx -3 Gs 2011 Toyota Rav4 1997 Toyota Corolla/ Total For Policy Coverages Total Policy Premium $ 188.10 $ 460.80 $ 186.70 $ 10.00 $ 845.60 How You Saved on this Policy with Nationwide • Accident Free • Multi Car • Passive Restraint • New Vehicle V-105(VA) • Affinity Continued on the next page Prepared on September 12, 2013 Page 2 of 4 Nationwide® Your Policy Declarations On Your Side For coverage definitions and descriptions, visit Nationwide.com Personal Auto Policy Policy Period: Sep 11, 2013 -Jan 19, 2014 Policy Number: 5345V 606818 Insured Driver(s) Name Abraham R Aragon Date of Birth 03/16/69 Marital Status Married Insured Vehicle(s) and Schedule of Coverages 1993 Mazda Mx -3 Gs VIN JM1 EC4326P0219038 Coverages Property Damage Liability Bodily Injury Liability Uninsured Motorists - Bodily Injury - Property Damage Limits of Liability $ 50,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Accident $ 50,000 Each Accident Premium $ 72.20 $ 80.00 Total for this Vehicle $ 33.70 2.20 188.10 2011 Toyota Rav4 VIN 2T3BF4DV6BW118914 Coverages Damage To Your Auto Other Than Collision (Comprehensive) Collision Property Damage Liability Bodily Injury Liability Medical Expense Uninsured Motorists - Bodily Injury -Property Damage Trans Expense -Rental Days Plus Opt 2 Lienholder-Wells Fargo Dealer Limits of Liability Actual Cash Value Less $ 250 Actual Cash Value Less $ 500 $ 50,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence $ 2,000 Each Person $ 50,000 Each Person $ 100,000 Each Accident $ 50,000 Each Accident Endorsement 3569 $ 900 Per Accident Lien Expires On Sep 11, 2017 Premium $ 71.70 $ 143.30 $ 80.20 $ 83.10 $ 28.10 28.60 2.20 23.60 Total for this Vehicle $ 460.80 Continued on the next page 03281002245033 Pel Prepared on September 12, 2013 Page 3 of 4 Nationwide® Your Policy Declarations On Your Side Personal Auto Policy Policy Period: Sep 11, 2013 - Jan 19, 2014 Policy Number: 5345V 606818 Insured Vehicle(s) and Schedule of Coverages (continued) 1997 Toyota Corolla/ VIN 2T1 BA02E9VC214626 Coverages Property Damage Liability Bodily Injury Liability Uninsured Motorists - Bodily Injury - Property Damage Limits of Liability $ 50,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Accident $ 50,000. Each Accident Premium $ 73.20 $ 82.70 Total for this Vehicle $ 28.60 2.20 186.70 Policy Level Schedule of Coverages Coverages Roadside Assistance Accident Forgiveness Feature - Currently Eligible To Use Vanishing Deductible Feature Limits of Liability Basic - Covers Disablement Up To $75/$100 Lockout $ 600 Trip Interruption Endorsement 3423A $ 100 Deductible Credit Endorsement 3550A Total for Policy Coverages Premium $ 10.00 Incl Incl $ 10.00 Policy Form and Endorsements V -045D Nationwide Auto Policy V -3131A Government Employees Using Autos in Government Business V -3159A Amendatory Endorsement - Virginia V -3230A Customizing Equipment Coverage V-3158 Amendatory Endorsement - Death Benefit (Seat Belt Extended Coverage) -Virginia V -3423A Roadside Assistance Coverage (Virginia) V -3550A Vanishing Deductible V-3569 Transportation Expenses Coverage - Rental Days Plus (Virginia) Continued on the next page Prepared on September 12, 2013 Page 4 of 4 Nationwide® Your Policy Declarations On Your Side For Office Use Only: 08/22/13 $ 0.00 Terr: 115 Issued By: Nationwide Property And Casualty Insurance Company Countersigned At: Lynchburg, VA. By: Leslie Tull Corrigan How to Contact Us Your Nationwide Agent Leslie Tull Corrigan 703.361.0233 Customer Service 1.877.669.6877 Internet Nationwide.com 24 -Hour Claims Reporting 1.800.421.3535 Hearing Impaired (TTY) 1.800.622.2421 Personal Auto Policy Policy Period: Sep 11, 2013 - Jan 19, 2014 Policy Number: 5345V 606818 k EXHIBIT E DCT -23-2013 13:25 DI (NOVA INOUA FAIRFAX 703 776 5902 P.02 FAIRFAX HOSPITAL DULAM,MRUDULA 3300 Gallows Road MRN: 13314239 Fairfax, VA 22042»3307 DOB: 41211984, Sex: F Adm:912912013, DIC:10/412013 Op Note signed by Tabbarah, Rami Zuhayr, MO at 09/29/13 0600 Author: Tabbarah, Rarni Service: Obstetrics Author Type: Physician Zuhayr, MD Filed: 09/29/13 0600 Note 09/29/13 0406 Note Type: Op Note Time: • Related Original Note by: Skora, Daniel A, MD filed at 09/29/13 0415 Notes: Pre -operative Diagnosis: ob code yellow, bradycardia by sonogram in ED, 25.1 wk IUP, s/p head on collision 30 minute time of arrival from incident Post-operative Diagnosis: complete placental abruption Procedure: stat C/D Surgeon: Tabbarah Assistant: Skora, Braverman O ,v9 /1 3 ;I"Anesthesia: GET % Estimated Blood Loss: 800 S�G�`' Intravenous Fluids: 2.5i. Urine Output: clear Findings: complete placental abruption, general surgery ran bowel with no findings of bowel injury Pathology: placenta Complications: none Condition: stable to pacu Findings: Delivery of a viable female infant,breech presentation with vertex extraction through classical incision, 11b513 oz, Apgars 0/3, complete placental abruption. Neonate was handed off to neonatology present. Placenta was delivered spontaneously and intact with 3 -vessel cord noted. Bilateral fallopian tubes and ovaries n,ted to be within normal limits. Description of Procedure: Pt was seen as 08 code yellow in the ED department. While being cleared by trauma surgery there, sonogram was performed. Of note there was poor visualization of cardiac activity, but with doppler imaging it appeared to have a bradycardia to the 90s -100s. Decision was made to proceed with stat CID in labor and delivery as cls tray not available in ER. CIS was called at 2:44am and the delivery was accomplished at 2:55 am. The patient was taken to the operating room where general anesthesia was performed and noted to be adequate. The patient was placed in the dorsal supine position with a leftward tilt. SCDs were placed on bilateral lower extremities. The patient was prepped and draped in the normal sterile fashion with splash of betadine. A Foley catheter was placed to allow bladder drainage, A vertical skin incision was made with a scalpel and carried down to the underlying layer of fascia . The fascia was Incised with the scalpel and extended bilaterally with blunt force. Both edges of fascia were extended with blunt force. The peritoneum was identified, entered bluntly, and extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted The uterus was incised with a scalpel in classical incision extended bilaterally manually. Of note, a large clot of -300 cc was first expulsed from the uterus: The Irstant's head was delivered atraumatically with the body following. The cord was clamped and cut. The neonate was subsequently handed off to awaiting neonatology. The placenta was delivered spontaneously. The placenta was noted to be shredded with a 3 -vessel cord noted. The uterus was cleared of all clots and debris. The fundus was noted to be atonic and 800 mcg of cytotec and methergine were given. The edges of the uterus were grasped with ring forceps and Allis clamps. The hysterotomy site was repaired with a running, locked suture of 0 -Monocryl. A second imbricating layer of 0 -Monocryl suture in a Lambert fashion was utilized for the hysterotomy closure. The gutters were cleared of all clots and debris and attention was returned to the uterine incision, which was found to be hemostatic. Generated on 10/23/2013 3:07 PM Page 1 OCT -23-2013 13:25 I NOVA FA I RFAX Q (NOVA 703 776 5902 P.03 FAIRFAX HOSPITAL DULAM,MRUDULA 3300 Gallows Road MRN: 13314239 Fairfax, VA 22042-3307 DOB: 4/2/1984, Sex: F Adm:9/29/2013, D/C:10/4/2013 At this time, trauma surgery scrubbed in and ran the bowel with no bowel injury noted. There was a vertical and horizontal defect in the fascia from blunt force of opening the pt. The fascia was re -approximated with two running sutures of 0 -PDS. The subcutaneous tissue was irrigated, Any bleeding was made hemostatic with the Bovie. The subcutaneous tissue was re -approximated with 0 -Plain gut running suture. The skin was re -approximated with staples. The patient tolerated the procedure well. All sponge, lap, and needle/instrument counts were correct times two. The patient was then transported to the PACU in stable condition. The patient received Anoef 2 grams prior to incision. D. Skora R4 Attending note: I was present scrubbed and participated in the above procedure. The baby's heartbeat was noted to be less than a 100 BPM and the the heart seemed to flutter and could not quantify hearbeat, Decision was made to perform a STAT cls in the ER but the ER reported not having a CIS set. The patient was counseled about the findings and decision was made to transfer to labor and delivery OR. The decision and the transfer and the delivery were accomplished between 2:46 am and 2:55 am. Patient arrived in the ED at 2:15 am. At 230 am sono was being performed and doppler and could not quantify heartbeat. ED did Chest xray and pelvic xray. Decision was then made to do a STAT c/s in the ED at 2:36am. ED reported having no C/S set. Patient transferred at 2:46 and baby was delivered at 2:55, Patient had complete abruption of the placenta and baby was limp and Apgar's 0/313. Trauma surgery ran the bowel and explored the abdomen. Incision was closed. END OF REPORT TOTAL P.03 EXHIBIT. F 1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 4g1110.WelegallOrf DIVISION IN RE: Estate of BABY -GIRL DULAM- : ICASIREDDY,. Deceased AND NOW, this NO.: 8 , 2014, upon consideration of the attached Uncontested Petition to Settle Wrongful Death and Survival Actions, it is hereby ORDERED and DECREED that Petitioners are authorized to enter into a settlement with Travco. Insurance Company in the gross sum of $100,000 for Underinsured Motorist Benefits. It is further ORDERED AND DECREED and thafthe settlement proceeds shall be distributed as follows: GROSS SETTLEMENT: $ 100,000 Wrongful Death (100%) $ 100,000 Survival Action (0%) 0 The Wrongful Death Action shall be paid as follows: To: Bharath Kasireddy and Mrudula Dulam $ 100,000 Approval of this settlement does not affect Petitioners ability to pursue a claim against Abrarn Aragcliii Or any other person or entity responsible for the death c;f Baby Girl Dularn- Kasireddy. ..• . • c, TRUE COPY FROM RECORD In Testimony whereof, 1 here unto set my hand and th se I of said Co)54at Carlisle, Pa. This 11N -day of , 20 Prot o omas A. Hooey Common Nem Judge EXHIBIT G GENERAL RELEASE FOR AND IN CONSIDERATION of the sum of One Hundred Thousand ($100,000.00) Dollars paid in equal shares of $33,333.33 to Bharah Kasireddy, Individually, Mrudula Dulam, and Bharah Kasireddy as Administrator of the Estate of Baby -Girl Dulam-Kasireddy (hereinafter referred to as "Releasors"), the undersigned does fully release and discharge Abraham Aragon, and his insurer, Nationwide Property & Casualty Insurance Company, and any and all persons, associations, and corporations whether or not named herein, their heirs, executors, administrators, successors, assigns and insurers, and their respective agents, servants, and employees (collectively referred to herein as "Releasees") from any and all causes of action, claims and demands of whatsoever kind or nature on account of all known and unknown injuries, losses and damages in any way connected with the motor vehicle accident which occurred on September 29, 2013, on Braddock Road and Fairfax County Parkway in Fairfax, Fairfax County, Virginia. IT IS EXPRESSLY UNDERSTOOD AND AGREED that this is a full and final release of all claims. IT IS EXPRESSLY UNDERSTOOD AND AGREED that this Release and settlement is intended to cover and does cover not only all now known injuries, losses, damages and claims under Pennsylvania's Wrongful Death and Survival statutes which arise from the subject motor vehicle accident, but also any further or future claims, injuries, losses and damages which arise from, or are related in any way to, the occurrence set forth above. -1- IT IS FURTHER UNDERSTOOD AND AGREED that this is the complete release agreement and that there are no written or oral understandings or agreements, directly or indirectly connected with this Release and settlement that are not incorporated herein. This agreement shall be binding upon and inure to the successors, assigns, heirs, executors, administrators and legal representatives of the respective parties hereto. THE UNDERSIGNED HEREBY DECLARES that the terms of this settlement have been completely read; that they have discussed the terms of this settlement with legal counsel of their choice and had an opportunity to ask questions of counsel pertaining to the terms and legal effect of this Release and settlement; and said terms are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims on account of the motor vehicle accident and related damages above-mentioned, and for the express purpose of forever precluding any further claims or suits arising out of the above accident. THE UNDERSIGNED DECLARE that they are executing this Release for themselves and as the legal representative of the Estate of Baby -Girl Dulam-Kasireddy, that they are authorized to enter into this agreement, that they are mentally competent to enter into this settlement agreement, that they have not been adjudicated incompetent or insane nor are they otherwise without the capacity to understand and appreciate the terms and finality of this Release and settlement. -2- IN WITNESS WHEREROF, we have hereunto set our hands this day of 2014. Witness Bharah Kasireddy Witness Mrudula Dulam Witness Bharah Kasireddy, Administrator of the Estate of Baby -Girl Dulam-Kasireddy 1595320.1 -3- IN RE: ESTATE OF BABY -GIRL DULAM- KASIREDDY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENSYLVANIA ORPHAN'S COURT DIVISION No. AFFIDAVIT OF BHARATH KASIREDDY I, Bharath Kasireddy, Administrator of the Estate of Baby -Girl Dulam-Kasireddy, state that the following facts are true and correct: 1. I am the Administrator of the Estate of Baby -Girl Dulam-Kasireddy, who died as a result of injuries sustained in a motor vehicle accident that occurred on September 29, 2013. 2. I currently reside at 416 Meadow Drive, Camp Hill, Cumberland County, Pennsylvania 17011. 3. I am the Decedent's father and live with the deceased baby's mother, Mrudula Dulam, and are the sole heirs of the decedent's Estate. 4. Following the motor vehicle accident, I entered into negotiations with Nationwide Property & Casualty Insurance Company on behalf of the Estate and reached a settlement whereby this company would pay the policy limits of Abraham Aragon in equal shares to Mrudula Dulam, the Estate of Baby -Girl Dulam-Kasireddy, and myself, $33,333.33 each. 5. I have had the opportunity to review the terms of the settlement over a reasonable period of time, I have had opportunities to ask questions of counsel pertaining to the terms and legal effect of the settlement, and acknowledge that the terms are fully understood and voluntarily accepted for the purposes of making a full and final settlement of all claims. 6. I, Bharath Kasireddy, verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §49o4 relating to unsworn falsification to authorities. Date: l0 —o4-o�ofrf Sworn to and subscribed before me this .D.Lf day of , 2014. Notary Pullic My Commission Expires: COMMONWEALTH OF PENNSYLVANIA (SEAL) 1595397.1 NOTARIAL SEAL DONALD TRAUBE Notary Public LEMOYNE BOROUGH, CUMBERLAND COUNTY My Commission Expires Jun 3, 2017 L910S1 Bharath Kasireddy CERTIFICATE OF SERVICE I, John F. Yaninek, Esquire, of the law firm of Thomas, Thomas & Hafer LLP, attorneys for Petitioner, do certify that on today's date, I placed a true and correct copy of the attached Petition for Approval of Wrongful Death and Survival Claims in the U.S. Mail, postage prepaid, addressed to: Shannon E. Baker Trust Valuation Specialist PA Department of Revenue Inheritance Tax division PO Box 280601 Harrisburg, PA 17128 THOMAS, THOMAS & HAFER LLP Date�� `, 2014 THOMAS, THOMAS & HAFER, LLP John F. Yaninek, Esquire Attorney I.D. No. 55741 P.O. Box 999 Harrisburg, PA 17108-0999 (717) 441-3952 F!LEO-OFFICF_ UF THE PROTF-IONOTARY NOV 13 AM 10: 04 CUMBERLAND COUNTY A ttornvE,RN.gsltitiNgRky-Girl Dulam-Kasireddy IN RE: ESTATE OF BABY -GIRL DULAM- KASIREDDY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENSYLVANIA No. 14 - (045q Oivi Mew ORDER AND NOW, this 3 day of Pete°~1114, 2014, upon consideration of the Petition for Approval of Wrongful Death and Survival Claims, it is hereby ORDERED AND DECREED that Petitioner, Bharath Kasireddy is authorized to enter into a settlement and sign a release for the Estate of Baby -Girl Dulam-Kasireddy's claim with Abraham Aragon and Nationwide Property & Casualty Insurance Company in the gross sum of $100,000 of which $33,333.33 are payable to Bharath Kasireddy, Mrudula Dulam and the Estate of Baby -Girl Dulam-Kasireddy. IT IS FURTHER ORDER AND DECREED that the settlement of the Estate of Baby -Girl Dulam-Kasireddy should be distributed as follows: (a) Wrongful Death 100% $33,333.33 (b) Survival Action -0- Wrongful Death Action proceeds shall be paid to the Estate of BABY -GIRL DULAM-KASIREDDY and distributed equally to Bharath Kasireddy and Mrudula Dulam. BY TH tribution List . Yaninek, Esquire, Thomas, Thomas & Hafer, LLP, 305 N. Front Street, Harrisburg, PA 17108 annon E. Baker, Trust Valuation Specialist, PA Department of Revenue, Inheritance Tax division, PO Box 280601, Harrisburg, PA 17128 CCY31.ES fr& IscL /3/ y