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HomeMy WebLinkAbout05-3797 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION HOLLY and SCOTT EICKMAN, as Parents and Natural Guardians of CRUZ EICKMAN, a Minor, Plaintiffs No. O~- _J,"i97 ~~d,~~ CIVIL ACTION - LAW v. LffiERTY FORGE HOSPITALITY, INC., Defendant PETITION FOR APPROVAL TO COMPROMISE. SETTLE. AND DISCONTINUE A MINOR'S CASE Petitioners Holly and Scott Eickman, as parents and natural guardians of Cruz Eickman, a minOf. respectfully petition the Court fOf approval of the settlement of a claim of their son, Cruz Eickman, and, in support, set forth the following: 1. Petitioners Holly and Scott Eickman are the parents and natural guardians of the Minor Plaintiff, Cruz Eickman, all of whom reside at 195 Vic Edwards Road, Sarasota, FL 34240. 2. Cruz Eickman, the Minor Plaintiff, was born on October 25,2001, and is currently three (3) years old. 3. On July 28,2004, Cruz Eickman was with his parents at facilities owned and operated by Defendant Liberty Forge Hospitality, Inc. ("Liberty Forge"), when he was knocked down by a dog owned by one of the ownefS of Liberty Forge ("the Incident"). At the time ofthe Incident, Cruz Eickman was sitting at a table located on a slightly elevated deck. The force of the Incident caused Cruz Eickman to fall off the deck. 4. As a result of the fall, Cruz Eickman suffered a left distal radius and ulnar buckle fracture. 5. Cruz Eickman was seen for his injuries at the Holy Spirit Hospital in Camp Hill, Pennsylvania, but, because the family was leaving to return to Florida the next day, no treatment was rendered. 6. Cruz Eickman was treated for his injuries by Daryl Miller, M.D., Gulf Coast Orthopedic Center, 4937 Clark Road, Sarasota, Florida 34233, who placed Cruz Eickman's arm in a short arm cast on July 30, 2004. The cast was removed on August 16, 2004. 7. On August 16, 2004, Dr. Miller released Cruz Eickman and indicated that he could resume normal activity. Dr. Miller has indicated that, in his opinion, Cruz Eickman is not expected to incur any future problems as a result of the July 28,2004, injury. See Dr. Miller's July 30, 2004, and August 16,2004, reports attached as Appendix A. 8. Cruz Eickman has not had any other medical care for the injuries resulting from the Incident except as referenced in this Petition. 9. Cruz Eickman has made a full recovery from the injuries he suffered in the July 28, 2004, Incident. 10. While Liberty Forge denies that it has any liability for the injuries to Cruz Eickman, it is willing to resolve all claims relating to the Incident for the amount of Eighteen Thousand Five Hundred Dollars ($18,500) ("Settlement Amount") to be paid for the benefit of Cruz Eickman in exchange for a full and final settlement of all claims and appropriate releases executed by Holly and Scott Eickman, as parents and natural guardians of Cruz Eickman and individually. 2 II. Holly and Scott Eickman and Liberty Forge believe that the Settlement Amount is a fair and reasonable amount to fully resolve all claims of both the Petitioners and of the Minor Plaintiff arising from the Incident. A copy of the Release which will be executed by Petitioners if this Petition is approved is attached at Appendix B. 12. Petitioners Holly and Scott Eickman request that the settlement of all claims relating to, or resulting from, the Incident in the principal amount of Eighteen Thousand Five Hundred Dollars ($18,500) be approved. 13. The settlement will be a structured settlement and the Settlement Amount will be used to purchase an annuity with Hartford Life Insurance Company, an A+ rated life carrier by A.M. Best Rating Service. The principal sum and accrued interest will be distributed on Cruz Eickman's eighteenth, nineteenth, twentieth, and twenty-first birthdays on October 25 of the following years: 2019,2020,2021, and 2022 respectively. It is anticipated that the four annual payments will be $9,320, for a total payout of $37,280. 14. The settlement will be arranged to maintain the tax-advantaged nature of a structured settlement and the obligations of Liberty Forge and Harleysville Mutual Insurance Company, Liberty Forge's insurer, will be assigned via a Uniform Qualified Assignment and Release to Hartford Comprehensive Employee Benefit Service Company ("CEBSCo") which will act as assignee. Hartford Life, Inc., will guarantee the obligation assumed by Hartford CEBSCo. A sample of the Corporate Guarantee is attached as Appendix C. 15. Because the Petitioners are proceeding pro se, there will be no attorney's fees paid as part of this settlement. WHEREFORE, Petitioners Holly and Scott Eickman, as parents and natural guardians of Cruz Eickman, respectfully request that the Court grant their Petition and approve the settlement 3 of the claims of Cruz Eickman arising from the Incident of July 28, 2005, upon the terms and conditions set forth in this Petition. Respectfully submitted, J.\~ ~ 'T,;,,, ""'" Holly Eic an 195 Vic wards Road Sarasota, FL 34240 (941) 378-3797 ~. Dated: Julyrz..:L 2005 195 Vic Edwards Road Sarasota, FL 34240 (941) 378-3797 Parents and Natural Guardians of Cruz Eickman 4 //~ - . L(~ . GULFCOAST ORTHOPAEDIC CENTER, P. . II &. V AlIa ASKINS, MJI. IIlUAlI A. SCROffttD, M.lI. J01II' D.IWQ), lItD. .j937 CL.UIC. ROAD SARAIOI'A. n. 342:13 PIlONi(9'I)34UoI04 'AX(!'4I)~ _~OM'l'ORTJlO.CO" ArllU,M.D. DAlM. ... MlLl.III, MoD. July 30, :1004 fr1'b--b 1~51S Eric G. Patrusky. D.O. S741.Bee Ridge Road, #350 SllI'UOta, PL 34233 lW: EICKMAN, CRnWS P.:ar 01-. Patn1lIky; The patient is here to see l:Ue today with . e.hief COInplaint of left wrist paiD. He a fiill several days ago While playm, with a s:i"1iDI. At tbat time x-rays were obtained. He was told he bad a ii'Ietut'e IIIld. wu seat 10 me tor evaluation. On discussion with the patient's mother! he has not had my prior il:ij\lries in the past. He is a healthy YOllll8 man Witl1l1O medical ptObItms. On pby5i~lIl ..,.",";..~filll1 oflll.e lell uppcc ~ty after mnovlll ofth~ spliDf, he . neurovucularly intact II1d movi1l.I all dialts. RADIOLOGIC DATA: Xoofa)'S dcmoJlltrate a buckle ft3cnue with auatomic ent on ~ and lateral -news of the dista1 radius II1d u1ua. which ill not involving the growtIl pJ1&te. OOMSSIQN: Left distal IlIdillB and ulna buclde fl:actmc. PLAN: Ai. tbis time the patimt is p~ in a short ann ~ with the: wrist in mum Il1l1uee weeQ fur cast n:movallllld Iq)cat xadioPlPhs. Rowin Siaeerely. Daryl. Miller, M.D. DMlevn (Dictated but not read) m/c0'd ,6900c6~,~, 01 S,V6 cv9 9Se SWlJ 83~ JI1N~ll~a[W ~d VS:C0 S00c as Nnf ** <:0'3E1l;jd 110101 *'" IDCKMAN, CRUZ 8116/04 #95428 The patient i3 status-poat left dlsta1 radius ftacmre. The patient SOt hill cast WIlt. His c;asl W85 removed. OIl physical examination, he i3 non1el\d!r at this rime. X-RAY SV ALUA'nON: X-rays demonstrate no displacement. IMPRESSIONIPLAN: The parie:n[ h..,> been in a cBSt fonlO8l'ly thJee weeks an<l I feel it is .l"Pl~pliate discontinue the cast and allow the patient to resume activity as tolerated. I will back on a pm basis. I llltP1aioed to the mother that hued Ol1tbe location oftbis do Dot expald my gowth plate distwbances. Duy! Miller, M.D. DM/em .-.n...C'f:;l....l t5900G5~,~, 01 S,~6 G~9 9S8 SW1) 83~ )llNl;jll~IW d~ pS:G0 S00G 0<: NOr SETTLEMENT AGREEMENT AND RELEASE This SETTLEMENT AGREEMENT AND RELEASE ("Agreement") is made this _ day of , 2005, by and among Holly Eickman ("Holly Eickman") and Scott Eickman ("Scott Eickman"), individually and as parents and natural guardians of Cruz Eickman, a minor ("Cruz Eickman"), (Holly Eickman and Scott Eickman collectively "the Eickmans"), and Liberty Forge Hospitality, Inc. ("Liberty Forge") and Harleysville Mutual Insurance Company. its insurer ("Harleysville") (the Eickmans and Liberty Forge and Harleysville collectively "the Parties"). WHEREAS, on July 28, 2004, Cruz Eickman was with his parents at facilities owned and operated by Liberty Forge when he was knocked down by a dog owned by one of the owners of Liberty Forge ("the Incident"); WHEREAS, as a result of the Incident, Cruz Eickman suffered a left distal radius and ulnar buckle fracture; WHEREAS, on July 22, 2005, the Eickmans filed a lawsuit against Liberty Forge, Docket No. (C.P. Cumberland), for claims arising from the Incident (the "Lawsuit"); and WHEREAS, the Parties are desirous of resolving all claims arising from, or related to, the Incident. NOW, THEREFORE, in consideration ofthe payments to be made pursuant to this Agreement and based upon the promises, representations, and covenants set forth in this Agreement. with the intent to be legally bound, the Parties agree as follows: I of 13 I. PAYMENT I. Liberty Forge agrees to pay the principal sum of Eighteen Thousand Five Hundred and 00f100 Dollars ($18,500.00) (U.S.) ("the Settlement Amount") in the manner set forth in this Agreement to the Eickmans in consideration for a full and final release, as more fully set forth below, of any and all claims which were, or could have been, made as a result of the Incident and in consideration for the other promises and covenants made by the Eickmans in this Agreement. 2. Upon the execution of this Agreement, and upon approval of the Court as set forth in Paragraph 20 below, Harleysville, on behalf of Liberty Forge, will cause to be purchased an annuity with Hartford Life Insurance Company in the principal amount of the Settlement Amount which will pay the following approximate amounts on the following dates: $9,320 - October 25,2019 $9,320 - October 25, 2020 $9,320 - October 25,2021 $9,320 - October 25,2022 payable to Cruz Eickman ("Periodic Payments"). 3. The Eickmans acknowledge that the Periodic Payments cannot be accelerated, deferred, increased, or decreased by them or any Payee, nor shall the Eickmans or any Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or otherwise. 4. Any payments to be made after the death of Cruz Eickman pursuant to the terms of this Agreement shall be made to Holly and Scott Eickman. The Eickmans may change any designation at any time, subject to state law, by written notice which is delivered to, received and accepted by Harleysville or its Assignee. The designation must be in a form acceptable to Harleysville or its Assignee before such payments are made to the designated person or entity. 2 of 13 5. The Parties acknowledge and agree that Liberty Forge and/or Harleysville may make a "qualified assignment" within the meaning of Section 130(c) ofthe Internal Revenue Code of 1986, as amended, of their liability to make the Periodic Payments required in this Agreement to Hartford Comprehensive Employee Benefit Service Company (the "Assignee"). This assignment shall completely release and discharge Liberty Forge and Harleysville from all obligations under this Agreement as are assigned to the Assignee, and the Assignee shall be the sole obligor with respect to the obligation assigned. All other releases that pertain to the liability of Liberty Forge and Harleysville shall thereupon become final, irrevocable, and absolute. Any such assignment, if made, shall be accepted by the Eickmans and all Releasing Parties without right ofrejection and shall completely release and discharge Liberty Forge and Harleysville from such obligations hereunder as are assigned to the Assignee. The Eickmans and all Releasing Parties recognize that, in the event of such an assignment, the Assignee shall be their sole obligor with respect to the obligations assigned, and that all other releases that pertain to the liability of Liberty Forge and Harleysville shall thereupon become final, irrevocable, and absolute. If the liability to make the Periodic Payments is assigned by way of a "qualified assignment, '1; A. such Periodic Payments must be fixed and determinable as to amount and time of payment; B. such Periodic Payments cannot be accelerated, deferred, increased, or decreased by the Eickmans; C. the Assignee's obligation on account of the personal injuries or sickness is no greater than the obligation ofthe person or entity who assigned the liability; and D. such Periodic Payments are excludable from the gross income of the Eickmans under I04(a)(2) ofthe Internal Revenue Code of 1986, as amended. 3 of 13 6. Liberty Forge, Harleysville, and/or the Assignee reserve the right to fund its liability to make Periodic Payments through the purchase of an annuity policy from Hartford Life Insurance Company. Liberty Forge, Harleysville, and/or the Assignee shall be the owner of the annuity policy and shall have all rights of ownership. Cruz Eickman shall be designated as the "measuring life" under the annuity policy. Liberty Forge, Harleysville, and/or the Assignee may have Hartford Life Insurance Company mail payments directly to the Eickmans. The Eickmans shall be responsible for maintaining a current and proper mailing address and mortality information to Hartford Life Insurance Company. 7. Neither Party shall be obligated to pay attorney's fees for any other Party to this Agreement. 8. The obligation of Liberty Forge, Harleysville, and/or the Assignee to make each installment payment shall be discharged upon the mailing of a valid check in the amount of such payment to the address designated by the Party to whom the payment is required to be made under this Agreement. II. RELEASES AND INDEMNIFICATION 9. In consideration of the payment of the Settlement Amount to the Eickmans in the manner set forth above, the Eickmans, individually and as parents and natural guardians of Cruz Eickman (collectively "Releasing Parties"), do release and forever discharge Liberty Forge and Harleysville, and their parent, subsidiary, related and affiliated companies, predecessors and successors, representatives, assigns, and insurers, and each of their past, present, and future directors, officers, employees, agents, attorneys, and stockholders (collectively "Released Parties"), from any and all claims arising from, or in any manner related to, the facts or events 40fl3 involved in the Incident, as well as all suits, causes of action, actions, claims, liens, demands, and costs of any kind, name, and nature, in law or equity, whether or not well-founded in fact or law, which the Eickmans have had, now have, or can or may have at any future time on account of, arising from, connected with, or in any way related to the Incident, or which could have been claimed by the Eickmans in the Lawsuit. 10. The Eickmans specifically intend to release and discharge the Released Parties from any and all claims and causes of action of any kind whatsoever, whether known or unknown, which may exist or might be claimed to exist at or prior to the date of this Agreement. The Eickmans waive any claim or right to assert that any cause of action or alleged cause of action or claim or demand arising from, or in any manner related to, the Lawsuit which has been omitted through oversight or error, intentionally or unintentionally, from this Agreement. ll. The release and discharge agreed to by the Eickmans in this Agreement applies to their predecessors, successors, heirs, executors, administrators, representatives, assigns, agents, employees, and any and all persons acting on their behalf, including all attomeys representing the Eickmans. This Settlement Agreement, and the releases, promises, and covenants contained in it, is made to compromise a disputed claim and avoid litigation costs and does not constitute, and shall not be deemed to constitute, an admission of liability or responsibility by Liberty Forge, Harleysville or any of the Released Parties, all of whom/which expressly deny any and all liability or responsibility to the Eickmans for all claims made in relation to the Incident. Further, Liberty Forge, Harleysville and all Released Parties shall not be estopped from, or precluded from, denying liability or responsibility for any of the claims asserted in relation to the Incident and/or Lawsuit in any forum or proceeding or for any other purpose. 50fl3 III. CONFIDENTIALITY 12. In further consideration of the payment of the Settlement Amount, and any other promises and covenants set forth in this Agreement, the Parties and all individuals employed by or acting on behalf of the Parties, including their attorneys, agree and represent that the existence of this Agreement, the Agreement itself, and the terms and conditions of the Agreement are and shall remain confidential. The Settlement Amount and all information contained in this Agreement shall not be admissible nor referred to, directly or indirectly, in any other suit or litigation or disclosed to others not a party to this Agreement, except pursuant to an order of a court of competent jurisdiction or by written consent of all Parties to this Agreement. 13. Notwithstanding the previous Paragraph, the Parties are permitted to disclose the existence of this Agreement and it terms to appropriate government officials as required by law, such as to the Internal Revenue Service and any state or local taxing authority, to their advisors specifically retained for the preparation of tax returns or similar government filings, and other persons or entities as may be necessary to fulfill the purposes of this Settlement Agreement 14. In the event that inquiries are made to any Party, or a Party's representative, from a person or entity not a party to this Agreement concerning this Agreement, the response to all such inquires shall be only that the Parties have amicably resolved their differences and that the Lawsuit has been dismissed. Further, the Parties, on behalf of themselves and all persons acting on their behalves, agree that they will not engage in any action or conduct which will damage or disparage the name, business, or reputation of any Party to this Agreement, or any ofthe Released Parties, whether such disparagement is undertaken unilaterally or in response to questions or solicitations by others. 6 of 13 15. In the event that any person or entity seeks disclosure of this Agreement and/or the information protected by it, the Parties agree that the other Party shall have an opportunity to appear and take whatever action it deems necessary to oppose or limit such disclosure. If any court order requires the disclosure of any of the terms of this Agreement or information protected by it, the Parties agree to use their best efforts to ensure that any such terms which must be so disclosed shall be kept confidential by that court and! or by other persons to whom such disclosure may be made, and any other person making such limited disclosure shall use their best efforts to limit the disclosure within the terms and spirit of this Agreement and to prevent or limit any further disclosure by requesting appropriate confidentiality orders or agreements in any other proceedings or disclosure situations. Under no circumstances may the Parties seek a court order requiring disclosure of this Agreement or the terms thereof in connection with any other litigation or dispute. The Parties agree that if any proceeding is brought against any of them to require disclosure of the terms of this Agreement, the fact of this Agreement, and the amount paid under this Agreement to any person, firm, organization, or corporation not a party to this Agreement, the Party(ies) against whom the proceeding has been filed shall IMMEDIATELY notify the other Party(ies) in writing of any such proceeding. Such notice shall be sent by certified mail, return receipt requested, to: Robert E. Kelly, Jr. Kelly, Hoffman & Goduto LLP Commerce Towers, lOth Floor 300 North Second Street Harrisburg, P A 17101 Telephone: 717-920-8100 Facsimile: 717-920-0691 rkellv(iiJkhgllp.com For Liberty Forge 7 of 13 Mr. and Mrs. Scott Eickman 195 Vic Edwards Road Sarasota, FL 34240 Telephone: 941-378-3797 For the Eickmans IV. MISCELLANEOUS 16. The Eickmans represent and warrant that no other person or entity has or has had an interest in the claims and causes of action which were the subject matter of the Incident and/or Lawsuit and which are the subject matter of this Agreement. The Eickmans further represent and warrant that they do not know of or believe that any other potential plaintiff(s) or claims exist arising out of the subject matter of the Incident and/or Lawsuit, that they have the sole right and exclusive authority to execute this Agreement and receive payment of the Settlement Amount, and that they have not sold, assigned, transferred, conveyed, or otherwise disposed of any of the claims and causes of action subject to and released in this Agreement. 17. The Eickmans agree and acknowledge that they accept payment of the Settlement Amount as a full and complete compromise of matters involving disputed issues and the controversy which led to this Agreement, and that neither payment of the Settlement Amount by Liberty Forge and!or Harleysville, or any actions or statements by its attorneys or representatives prior to, during or following the Incident, shall be considered an admission of any liability or wrongdoing by Liberty Forge, Harleysville and/or its attorneys concerning any matter which was or could have been raised in the Lawsuit or any other lawsuit. It is further understood and acknowledged by all Parties that this Agreement does not constitute an admission ofliability or wrongdoing on the part of Liberty Forge, Harleysville and/or its attorneys for the claims arising out of the Incident, and that this Agreement is purely an act of compromise. 8 of 13 18. The Eickmans agree that the Settlement Amount is a fair and reasonable settlement of their claims arising out of the Incident and which were or could have been made in the Lawsuit and further warrant that they have entered this Agreement voluntarily and of their own accord, without reliance on any inducement, promise, or representations by Liberty Forge or Harleysville, the Released Parties, or any other party, except those which are expressly set forth in this Agreement. 19. Each ofthe Parties to the Agreement warrants and represents that they/it has the requisite power and authority to enter into this Agreement and that any and all authorizations or authorities necessary for the execution, delivery, and performance of this Agreement have been duly obtained and issued, and that this Agreement is legal, valid, and binding upon each of the Parties. 20. It is understood by the Parties that the Eickmans must, and will, file a Petition for Approval to Compromise, Settle, and Discontinue a Minor's Case ("Petition") seeking the approval of the terms of this Agreement and to permit them to release the claims released in this Agreement by Cruz Eickman from the Court of Common Pleas of Cumberland County, Pennsylvania. Liberty Forge and Harleysville agree to cooperate in the proceedings necessary to obtain such approval. It is further understood that, if the Court does not approve the Petition, then this Agreement shall be null and void and without prejudice to the rights of the Parties as they existed prior to the execution of this Agreement 21. Immediately upon the final execution of this Agreement and the payment of the Settlement Amount, the Eickmans agree to take any and all actions necessary to cause the dismissal with prejudice of the Lawsuit and to provide Liberty Forge's attorney with satisfactory 90f13 evidence of such dismissal. To the extent necessary, Liberty Forge and/or Harleysville will assist in any manner reasonably required for the dismissal of the Lawsuit. 22. The Parties to this Agreement will cooperate fully and take further actions and execute all further instruments and documents as may be necessary or appropriate in order to carry out the purpose of this Agreement. 23. It is understood by the Parties to this Agreement that the facts upon which this Agreement is based hereafter may prove to be other than the facts known by, or believed by, them to be true at the time of the execution of this Agreement. Each Party expressly accepts and assumes the risk that the facts may prove to be different, and each Party agrees that the terms of this Agreement shall be effective and not subject to termination or rescission by reason of such difference in facts. 24. It is understood and agreed by and among the Parties that no advice has been given by Liberty Forge and/or Harleysville or its counsel to the Eickmans regarding any issues of taxation relating to the Settlement Amount to be paid under this Agreement. The Eickmans acknowledge and recognize that all responsibility for the payment of appropriate taxes related to the Settlement Amount, if any, is theirs and agree to and will indemnify and hold harmless Liberty Forge and Harleysville from any and all taxes, interest, or penalties assessed by any federal, state, or local government as a result of the payment of the Settlement Amount. 25. This Agreement contains the entire agreement by and among the Parties with regard to the matters set forth in this Agreement. There are no other understandings or agreements, oral or otherwise, relating to the settlement of the Incident and Lawsuit, except as set forth in this Agreement. This Agreement shall not be modified or amended except by a writing signed by both Parties. 10 of 13 26. This Agreement, including its validity, shall be construed in accordance with, and governed by, the laws of the Commonwealth of Pennsylvania applicable to contracts and instruments executed and to be performed entirely in such state without regard to any choice or conflicts oflaw provisions requiring reference to the rules of, decisions in, and/or laws of another state or sovereign nation. Jurisdiction over any disputes arising under this Agreement, or actions to enforce any provision of this Agreement, shall be in the Court of Common Pleas of Cumberland County, Pennsylvania. 27. If any Paragraph, provision, or clause of this Agreement is found by a court of competent jurisdiction to be invalid or unenforceable for any reason, then such Paragraph, provision, or clause shall be construed so as to render it enforceable to the extent possible. Ifno possible interpretation would save such Paragraph, provision, or clause, it shall be severed from this Agreement and the remainder of the Agreement shall remain in full force and effect. 28. No provision of this Agreement is to be interpreted for or against any Party because that Party or that Party's legal representatives drafted or participated in the drafting of the Agreement or any provision of the Agreement. For the purpose of the construction and interpretation of this Agreement, each Party will be deemed to be the drafter ofthe entire Agreement. 29. The Parties agree that the terms of this Agreement shall be binding upon and inure to the benefit of the Parties and their respective representatives, heirs, executors, administrators, assigns, predecessors, related and affiliated companies, and successors in interest. No other person or entity shall acquire or have any right under or by virtue of this Agreement, except as expressly set forth in this Agreement. 11 of 13 30. This Agreement may be executed in counterparts, each of which will constitute an original and, taken together, shall constitute one and the same instrument. 31. The effective date of this Agreement shall be the date upon which the last signature necessary for the Agreement's complete execution shall be made. 32. The Parties declare that the terms of this Agreement have been completely read, fully understood, and acknowledge the right to seek independent legal counsel concerning the Agreement and voluntarily accepted for tbe purpose of making a fun and final compromise adjustment of any and an claims wbich were raised or wbicb could bave been raised in tbe Lawsuit. IN WITNESS WHEREOF, and intending to be legally bound, the Parties set their hands and seals on the date first above written. an, Individually and as Parent Guardian of Cruz Eickman cott Eic lIividua yand as Parent and Natural Guardian of Cruz Eickman Sworn to and subscribed before me this ;j~daYOf J~t0 ,2005. NOTARY PUBUC.S1'ATE OF FLORiDA Judith L. Toles . !i 22, 20{)9 Bonded Thng:;;;;t;!,~ 12of13 Attest Attest 13 of 13 Liberty Forge Hospitality, Inc.: By: Its: Harleysville Mutual Insurance Company By: Its: ~~ ~J > I > ) . I . I I I Q.) ~ ~ 8 ~ o Q.) c.,) = ~ e> ~ .s ~ "2 ~ ~ ~ ..2~rN 1::0 ~ 0 8 ~ v ~ "1:l U C\I l:l ~ ~ ~ 15 N ~ 'S ~BU;Ii~ ~'i-e~2ib it 1 ~ j j .g at.5.s'i:>' :r:l;1 .g >- t:l ..... "0 1; !;jooeg.. ci':tc.Og<i'la ~ .g .~ ~ -;; ~ u IJ~UlIlol!!" .l:l ;;:l .. ~ .tj 0 ~ Cl ..Q .u u ~ .::; 13 '15Jl e-e'" ShO "0 a ~ ~ .s il .s 12"~~"Oo" dlj1~Jl~~ .{! .. ~ .s ~ ~ -e >,"' "0 ;::l~ ~"2~..~-e!ii ., ? .9 ~ ~ " :r: fEI~E~.s .. "' P * .~ ~ 0 i9 .~ ..: '" ~ 2 U o.,l:j" c.CIl '::1 .. .., .15 1l - B ...E ~ ..t; ~ ~ ~ ~ ~ a.:a :~ ~ o~soC"e] '::o8~~~~ 8j;j"a""'~la~ ~"O~~~~-oO ::l 1;j :s 00 ~ tl< ~ g g ~ 1l "' p. '15 .a rt '1 l~ j 1 .. ~ :a J 'tl :.c! u oJ' Ii ]] i1;-"" - d:.8 ~ ~~~1! .~ .~ oJ! IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION HOLLY and SCOTT EICKMAN, as Parents and Natural Guardians of CRUZ EICKMAN, a Minor, Plaintiffs No. v. CIVIL ACTION - LAW LffiERTY FORGE HOSPITALITY, INC., Defendant VERIFICATION 1, Holly Eickman, hereby depose and state that I have read the foregoing PETITION FOR APPROVAL TO COMPROMISE, SETTLE, AND DISCONTINUE A MINOR'S CASE. The factual statements contained therein are true and correct to the best of my information, knowledge, and belief. This statement is made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities, which provides that, if] make knowingly false statements, I may be subject to criminal penalties. 'l 77 (\'"') Date j~ \\~"L\~\~C5" Holly Eic an IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL V ANlA CIVIL DIVISION HOLLY and SCOTT EICKMAN, as Parents and Natural Guardians of CRUZ EICKMAN, a Minor, Plaintiffs No. v. CIVIL ACTION - LAW LIBERTY FORGE HOSPITALITY, INC., Defendant VERIFICATION I, Scott Eickman, hereby depose and state that I have read the foregoing PETITION FOR APPROVAL TO COMPROMISE, SETTLE, AND DISCONTINUE A MINOR'S CASE. The factual statements contained therein are true and correct to the best of my information, knowledge, and belief. This statement is made subject to the penalties of 18 Pa. C.s.A. 94904 relating to unsworn falsification to authorities, which provides that, if I make knowingly false statements, 1 may be subject to criminal penalties. 7 - /J.S -0 ,,,> Date CERTIFICATE OF SERVICE On this _ day of July 2005, we, Holly and Scott Eickman, parents and natural guardians of Cruz Eickman, a minor, hereby certifY that we have caused to be served a true and correct copy of the foregoing PETITION FOR APPROVAL TO COMPROMISE, SETTLE, AND DISCONTINUE A MINOR'S CASE upon the person(s) and at the address(es) below named by hand-delivery: Robert E. Kelly, Jr., Esquire Kelly, Hoffinan & Goduto LLP 300 North Second Street 10th FlooT Harrisburg, P A 1710 1 Counsel for Defendant .,~J ~ 0 ~ r--..' ~ .~ ,- .) 0 '.-.J .1'1 ~. -'] c_ ...... "' f:;,'~ ---- ........ Cr( C,) . ........ C.\ ~ 6' () ~ ~ ~ ii V ;'-1 t r: ~. ~ ~ --t:- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION HOLLY and SCOTT EICKMAN, as Parents and Natural Guardians of CRUZ EICKMAN, a Minor, Plaintiffs No. ()S-.Y797 (!;Ul'~J CIVIL ACTION - LAW v. LIBERTY FORGE HOSPITALITY, INC., Defendant ACCEPTANCE OF SERVICE I hereby accept service of the Writ of Summons that was filed in the above-captioned action on July 22, 2005, on behalf of Liberty Forge Hospitality, Inc., and certify that I am authorized to do so. KELLY, HOFFMAN & GODUTO LLP Dated: ..Jv1'l ZZ,?60~ I Robert E. elly Jr., Esquire Commerce wers - lOth Floor 300 North Second Street Post Office Box 62003 Harrisburg, PA 17106-2003 Counsel for Liberty Forge Hospitality, Inc. CERTIFICATE OF SERVICE On this 26th day of July 2005, I, Pamela L. Russell, a legal secretary in the law firm of Kelly, Hoffman & Goduto LLP, hereby certify that I have caused to be served a true and correct copy of the foregoing ACCEPTANCE OF SERVICE upon the person(s) and at the addressees) below named by hand-delivery: Holly and Scott Eickman 195 Vic Edwards Road Sarasota, FL 34240 Counsel Pro Se c '(, r,,' C~ r~.) (:..0.., C) -n ':; r.~ \? (J ."j", '1 t'5 in I ('0,) C.<"\ -.I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION HOLLY and SCOTT EICKMAN, as Parents and Natural Guardians of CRUZ EICKMAN, a Minor, Plaintiffs No. 05-3797 Civil Term v. CIVIL ACTION - LAW LIBERTY FORGE HOSPITALITY, INC., Defendant ORDER AND NOW, this U day of \'" ~ !fA \ Petition for Approval to Compromise, Settle, and Discontinue a Minor's Case submitted by Holly ,2005, upon consideration of the and Scott Eickman, as parents and natural guardians of Cruz Eickman, and after a hearing on the Petition occurring on July 28, 2005, it is hereby ORDERED and DECREED that Petitioners Holly and Scott Eickman be, and hereby are, authorized to settle the above-captioned action for and on behalf of Cruz Eickman, a Minor, for the total sum of EIGHTEEN THOUSAND FIVE HUNDRED DOLLARS ($18,500) ("Settlement Amount") upon the conditions that the full Settlement Amount be utilized to purchase an annuity with Hartford Life Insurance Company for the benefit of Cruz Eickman, that the annuity pay all principal and accrued interest in equal installments to Cruz Eickman on October 25,2019,2020,2021, and 2022, and that obligations of the Defendant Liberty Forge Hospitality, Inc., and its insurer, Harleysville Mutual Insurance Company, in this matter will be assigned by means of a Unifoffil Qualified Assignment to Hartford Comprehensive Employee Benefit Service Company. ~- BY THE CO~ Cr' \ ...... Ed ar B. Bayley, J. - /'- ~ ~.~ 'S;; .-\ -r -'1;"_ "'\"\f.:: '" C~" ...,., - ~":~ .r;'" -.':1;. C) 17'