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Home My WebLink About05-3889 STATE AUTO INSURANCE COMPANIES Plaintiff v. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 05"- 38 ~q ~ IQ.-v- R. HART ENTERPRISES, INC. Defendant(s) : CIVIL DIVISION ' LAW NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney filing in writing with the Court your defenses or objections to the claims set froth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION TWO LIBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 STATE AUTO INSURANCE COMPANIES Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 05- 3n'Q tuM -r;:.... R. HART ENTERPRISES, INC. Defendant(s) CIVIL DIVISION, LAW COMPLAINT The Plaintiff, STATE AUTO INSURANCE COMPANIES, by its attorneys, KNUPP, KODAK & IMBLUM, P.c., brings this action of Assumpsit against the Defendant to recover the sum of FOUR THOUSAND, ONE DOLLARS AND SIXTEEN CENTS ($4,001.16), along with interest thereon from October 5, 2004 upon a cause of action of which the following is a statement: 1. The Plaintiff, STATE AUTO INSURANCE COMPANIES, is a company organized and existing under the laws of the State of Ohio, having its principal office and place of business at 518 East Broad Street, Columbus, Ohio 43215. 2. The Defendant, R. HART ENTERPRISES, INC. is a corporation organized and existing under the laws of the Commonwealth of Pennsylvania having and office and principal place of business at 1200 Rossmoyne Way, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On or about March 1,2001 Defendant did submit an Commercial Insurance Application to Plaintiff for purpose of obtaining insurance. A true and correct copy of said Application is hereto attached, marked Exhibit "A" and made a part hereof. 4. Subsequent thereto, Plaintiff did provide Commercial General Liability Insurance for the benefit of Defendant for the period of February 25, 2003 through February 25,2004. F:IUSERIST ACY\CCP COMPLAINTSIWORKISAIC31441.wpd: 10lul05 2 5. The prices charged for said insurance coverages provided were just and reasonable, were the legal and market prices therefor, and were the prices which the Defendant promised and agreed to pay Plaintiff therefor. 6. Defendant defaulted on his obligation to pay Plaintiff the premiums when due. 7. The balance due and owing by Defendant to Plaintiff is the sum of Four Thousand, One Dollars and Sixteen Cents ($4,001.16), as appears by Plaintiffs Invoice hereto attached, marked as Exhibit "8" and made a part hereof. 8. Plaintiff frequently demanded payment from Defendant of said amount due and owing as aforesaid, but Defendant refused and neglected and still refuses and neglectd to pay said amount of any part thereof. WHEREFORE, Plaintiff brings this suit to recover from Defendant the sum of FOUR THOUSAND, ONE DOLLARS AND SIXTEEN CENTS ($4,001.16), along with interest thereon from October 5, 2004. Respectfully submitted, KNUPP, KODAK & IMBLUM, P.C. Robert D. Kodak 407 North Front Street Post Office Box # 11848 Harrisburg, P A 17108-1848 (717) 238,7151 Attorney ID No. 18041 Attorney for Plaintiff F:\USER\ST ACYlCCP COMPLAINTS\WORK\SAlC31441. wpd: 1 OJul05 3 H T , ACORD~ COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION PROOUCER ~gNJo ll.l' 7'" 0<01'-82.8.0 CARRI;R St?te Auto Insurance UNDERWRITER . _,~EJ_ -"-J~ - --- C' ,Tod Bergen AlA, lne. ompanles ' 45'50 Lena Drive POUCIES OR PROGRAM REQUESTED BINDER48276 Mechanicsburg, PA 17055 II INDICATE SECT\ONS ATTA.CHEO X ~ EQUIPMENT FLOATER GARAGE AND OEAL~S pro, ducer: :Leon. Feinerman. A.. PROPERTY ___INsrAllATION/BUILOERSRISK_~ VEHIClESCHEDUlr, CBR~~araJ_CQx---,.>_ ______~.____~ --.-: GLA$SF>.NOS)Gti ~~ ElECTRONICOATAPROC BQllE.R& MA.CHINE -CODE: I I SUB CODE: e~E8AUJt1Sp'l~~~~A8lE! ,..--lL g~~r~R8fp,'aILlTY WORKERS COMPEN ArrON AGENCY CUSTOMER 10 - -----.-~-" ~ - CRIME/MISCELLANEOUSCRIME BUSINESS AuTO UMBRELLA - TRANSPORTATION! MOTO~ TRUCK CARGO DATE IMIIA ) 03(01 01 20693 STATUS OF SUBMISlSION , TRUCKERS QUOTe PACKAGE POLICY INFORMA TlON ENTER THIS INFORMp..T10NWHEN COMIvlO/'!_EJ_ATES A~D ~MS APPl.,!10S~~~A.ll\N'E.~.Ofl. FClf\ MONO\...\WE. I ISSUE POLICY ~ .L SOUND (Giv. Date anatet Attach Copy): OAT< I nME 02/25/01 ,12:01 APPLICANT IN FOR TION N~r{ IFHAYiTat?f<Lp~TS€i~ur;;\C PROPOSED EFF DATE pROPOSEO EXP OA TE BILWiG PLAN _~_' DIRECT BIll AGENCY BILL PA 1MENT PLAN l\CIE.'& AUDIT J<...: AM PM 02/25/01 02/25/02 Quarterly ~"OO."'"~ --. "-' R. Ro" 'no',", i "en, ,"0. no "wa'ai'-",o"" -ie'nn "J ',j 17113 X INDIVIDUAL CORPORAT10;---_ ~ S~BCHAPTER S' CORPORATlQN --- -. - -- =-=~ NQ~ P;;;T YEARS IN .US1NES$ PARTNERSHIP , JOINTVENTUAE QRGANIZATlON B~ tHSPEC110N CONTACT - P~gN~o El-fF-71 J - 939 - 3-0 96 -~~ ACCoUtm"Gf'.ECQRCSCO"""'CT ~.H~...fWi.~.= =.-- --- Richard Hart ( .J, H AiUY Same PREMISES INFOR ON r LOC,. BLot l STR.~ET.CllY,COUNlY.STAiE,Z1PCOOE.~__~~~Mtl'S..___~_~_~__ YRBU~ _' PARTOCCUPIEO 1 1 328L Swatara St. Steelton ~ INSIDE X OWNER 1997 100% Dauphin County, PA 17113 OUTS'OE TENANT 2 1 330, Swatani'si::'-Steelto-n X 'NSIO~-:X OWNER ---1-997 100%'--- Daufhin County, PA 17113 OUTSlOE ;ENANT (See Attabhed Preni"ises-Schedule:1 '---~..-..~---- .~.. --- OUTSJOE TENANT "I'" ,URE OF BUS!NE SlOESCRIPTIOIl OF OPERATIONS BY PREMISE(S) GENERAL INFORMA ON EXPLAIN ALL -YES. RESP SES 1. IS THE APPtlCANT A SUB~'DJARY OF ANOTHER ENTITY OR DOES THE APPL1CAN'T HAVE ANi SU8SIDlARIES? 2. IS A FORMAL SAFETY' PA RAM fN OPERATION? 3. ANY EXPOSURE TO fJ..AM' lES. EXPLOSNES. CHEMICAlS? RElIlA.RKS Home builded and remodeler YES NO 'EXPLAIN AL.1.. ""ES" RESPOKSES. s "0 .c, AN1 CATASTnOPHE EXPOSURE"~._.. : X ' 5. ANY OTHER II/SURANCE WITH THIS COMPANY OR BEING SUBt.lITIED7 , ' X ~ 6. AN'!" POliCY OR COVERAGE DEClINE.D CANCELLED OR i i NQN,-RENEYv'ED DURING THE PRlOR3 YEARS? APP'UCANT'S SIGNAitJRE ACORD 12513193)1 of I 1340 PL T L '" ACORD CORPORA TIO 1993 -' -..-- PREMISES INFORMATION (Continued from page 1.) . . , LOeir 6l.Qjt " STREET, CITY, COUNTY, STATE. Zif' CODE CITY UMITS INTEREST : YR BUILT, PARTOCCUP/EO I 3 1 i332 $watara St. Steelton, X fN,sIOE X OWNER ,1997 100% Iswatiltra County, PA . OUTSIDE TENANT I ~ -'- I 4 1 :418-420 Swatara St. Steel ton, :L, INSIDE -{.: OWNER 1997 100% swatira County, PA OUTSIDe. 'EN)l..N, ~ ---. 5 1 414 <tatherine Street Steelton l,II1SIOE X OWNER 1997 100% , Da~phin County, PA 17113 OUTSIDE TE....ANT - -'- , 6 1 1414 essamine Street Steel ton X INSIDE ,.~ QlNNER 1999 100% , Da phin County, PA 17113 OlJTSIOE TENANT - .- I 7 1 '408 ,essamine Street Steel ton X INSIDE X OWNER 1999 lOD%- ;, Da~phin'County, PA 17113 OUTSIDE TENANT - _. I , I INSIDE CM>lER -~ -_. I OlfTSIOE TENANT . - --. INSIDE O'NNER - ._. 1 OUTSIDE TENANT , I - - INSIDE O'M'lER - OUTSIDE TENANT -- .- INSIDE OWNER - - 1 OUTSIDE TENANT I - -, : INSIDE CM>lER 1 - .,"-- I OUTSIDE TENANT , ----~ -, , I INSIDE OWNER - _. I OUTSIDE TEliANT '- _. I ) INSIDE CM>lER , ,- _. I ourSIDE TENANT I .- -- I INSIDe OWER - _. OUTSIDE TE NANl i - _.-. , I I INSIDE OWNER I -' -' , OUTSIDE TENANT - -- I ' INSIDE OWER , I ~ - I QVTSJOE TENANT - - I I : -----' INSIDE OWER - OUTSIDE TENA.NT I - -- , I INSIDE OWNER I ..----' ._-. I i \ OVTSloE TENANT - --. I INSIDE OWNER ,- - OUTSIDE TENANT I - --, , I . ; INSIDE OWNER , ~ - i I QVTsloe T<"""T - - , , , CISGEI.I 125,4 (3193\3 or 3 #1340 .. ---~_._-- - . 1 PRIOR CARRIER IlfORMA TION .~__ YEARS~____~:~~;.~ UN' _~1!~~__~:_~_8>-=__nl__-- YEARS: YEAR.S: --- --._--- --- ----~----- - ""~____I_--.-PresqueJsle . '> .------- -. - ~._-- ~~~0Y NU.MBER ~ PKF2 0125~413" -l______~__ -- ...;-- ,- e:::'e~'_X~:lJRRH'CE tv."") ! ' tLA''') , OCcU~U'l(:E C""''''):. ocw..u~C( "";S ~~, .!~~_~_L~ OCC"""f~( ."!.!I ~--~g~ ..I---->------"!.~L.......:.._~__~...2!t?!_..______._ -- RETRO DATE ----- -:----t~- G .-"-<NeRAL AGGi\<GAT,,-2~ _0.0.0, ..0.0 Q_ --------1 , e r~~~g~~~P OP 2-1 J1Dlt,_OD_O .- - ------ N , ._-_._,.~.._._--~-'- , CR PERSONAL &. A~Y INJ 1. ._0Jl.04..0_o..o --. ---- -~-_.- -- 0. '-- ~L E.ACH OCCURR'NCE ll_QQ.O.I_Q_O_Q___ ---"- --_.- -- .._-------,~~- .. . L R l , FIRE DAMAGE ~o 0 . ODD - -------- ------,- -.--- .., ,.. c , M - MEDICAL EXPj;;-~~ 5 . -0.0-6-- ---' A , " T A , OCCurRENCE II S BODILY ----~--_.~-_._~.- I INJURY ~GG~ECJ\ TE - T ,-- -r---~'-- --'- ~ --, -.- ---- - -' --.---- , ----- ~,-- y PRCff.RTYOCCtfRENCE. ~--~- --~----'._--~- DAMA.GE AGG1EGATE , .-. -. --~--- ----- -. - -' - - ----- COM61NEO S(NG~ \.IMIT --, , ..- ---~-- -'- ~--- MODIFICATION FA TOR -~-----~-_.~----- TOTAL PREMIUM I 3 482 CARRIER -----~------------- POLlCY NUMBER I -------- ~ - .----- ,- ---- .------- - -.------. A l POLlCY 11'PE ~ U '- .- ----------- -- - ... -.'- -- -,- -" - -_.-'--,- -- , ~a SlNGl~L~~\T T A o. ~~ON ____ ---~-- - ,-- ~--~--- - --~--- ,- ----.- - -------- - -, M, BODILY --..- --- o l ----- - - -- .- -' - -- -,.. -. .- --------- - -_.- - .- '- -----._- ., INJURY EAACFIOENT ._____~__ , T -- ,.- - ._--~-- ~. --.--- - --~--- ------~ --~- ~----- € V PROPE.RTY OAMII.Gt --~_._---------- - _.--- -'- --- -"~- ------ - ~ MOOIFICATJON FAC,OR ,--- -- ------- ~------------- ~ -' - - TmAl PREMIUM CARRIER , Presg"'~-.-1@J<=.. ....___,___.__ - -,- - --------.-------- P PO~/CY NUMBER , P_KF2017.,51_413_._ .. R _.- .--- --- - --------- --,---- - _. 0 I Pack~g~_,_._,_~ p ?OLICY TYPE --, - - - --.---------- - - - . BlO : ~~~ AMT R ----------- - -"-- ,- .--.-. .. - ,-- ..,- ,- -. .---- .. T MODIFICATION FAC R V ----. -. ------ -, - -------- - .-- -"--'-~ --._- -- - .. . T01AL PREMIUM , Included CA.RRIER I Eg,u.iJl..fl.J:L_ _ -~----- ----~--- ------~----- ---- ,- . POLICY NUMElER I PKF201.757413 ------- ---,- - ------ - - -.------ -, -~._.-- ,_...- -- --- - P-OIJC)' TYPE I 'Package ==- - ------- - -.-------.---.----- ~L~_4__-------~- .-- --'---'-- -- MODIFICATION FAcrtR Included --.- , ----- ------------~- TDTAL PREMIUM LOSS HISTORY , fNTfR ALL CLAIMS OR OCC RRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE: PRIOR 5 YEA.RS_ _____ _ ~K HE.RE ~_o~~ .~ 5EEAlTACHED L~SSU MARY DATE OF UNe TYPElDESCRlP110N OF OCCURRENCE OR ClAIM OATE A.MOUNT AMOUNT ~~IM OCCURRENCE , OF CLAIM PAID RESERVED ATUS , , I I ~~ I : e~ouo , orEN I , C'I>>U> "" , I I - C(M.I;O I , , , - , , 1\ - ClC'Sl!O I I I , "" I I , =n' REMARKS NOTE: FIO'EUTl' RE~UIRE5 A FIVE YEAR LOSS HlSTORY I , ACORD 125 (3/93)2 of 13 H1340 'HARTR ACORD~ PROPERTY SECTION OA TE {MMlDDIYY1 PRODUCER I AlA, Ine. J 4550 Lena D:J1ive Mechanicsburg, PA CLIENT# 20693 03/01/0 APPUCtiNT ((lfSINamedlfln.'edj Hart, Richard P. Jr. & Nancy' .E~rt Enterpr~~gE!.L...!nc i__,__ PROPOSED EFF. DAT'E ~~OPC~,~:~:~~__~_ ~~I~I~1?~lAli __ _ _~YMEIi1' PLAN I AUDIT 17055 02/25/01 02/25/02 :_; AGENCY "___.,__,__. ____Z~~c~ ___ Quarter '~ \ I FOR cQiii>A'Ny USE- ONLY PREMISES INFORMA T ON , SUBJECT OF INSU~NCE AMOUNT ~ ',Loc #1 Bu~lding$95, 000 E , . L NO'Loc #2 Bu lding$9'5,000 COJNS %VALUAT10.N~USE~~F LOS~~~~~~]~ _~_~CUCllB_L~_.__~R~S AN~ co~omo~s T~PlY ~ 80% RC Special $250 New Const 1997 80% RC Special $250 New Const 1997 All Frame ~~NGIMPROVEMENTS ~ WIRING. 'fR: , ROOFING, YR. RIGHT EltpQSURf &. DISTAKC : _ll..i.__ __~, __ __. PLUMBING. YR HEATING. YR OTHER \.. -- -----.$250 -New 'Const 1997 \ ,I $250-"NewConst'1997-,;/7 I - -.-.,------ -' I" dPo~'1 1 ~ ,Loc #3 Bu Iding$95,000 80% RC Special g I Conten~__j;XL 000__, _'~L__SpeciaL_ NO, [Loc #4 BU:Ulding$105, 000 80%' RC Special 1 I ~ AOOrnO~j1.l COVERAGES, R TRlCilONS. EN-OORSEMENTS ANa AAnNG INFOfl,MAOON -.- -.---- -. ---- .CONSTRUCliON TYPE . - - Pi"or:cL. 'STORIES ---'BASM~ YR. BUILy--rOTALAREA-- - OTHER OCCUPANCIES'- LEFT EXPOSURE I. OISTAf.lCf --- ---;fEAREXP05URE&OISTAN~-~ BURGLAR .ALARM TYPE --CERTIFICATE.._____--- --eXPIRATION DAiE-- .-E:XTE'Nr-GAAiiE-~ENTRALSTATlON WITH KEYS BURGLAR ALARMINS1AL.LeO NO sER"vlceOSy _. --.. _. "ioUARPSmATCHMEti- ~- ClOCK JoiOURl Y FIRE PROTECTION ISPrinkler~, Slandpipes, CO-;!HOIlon sY$iem;,------- ~ - --ARE ALARM MANUFACTURER ~_u CENTRAL STATlON 2 B \ Loc ~ "I G , NO, I I 1 I I , ADDITIONAL COVERAGES. RESrcnONS. ENOORS"EMEHTS AND RA T1N~RMA nON -- --- -. All square fei"t is apgoximately : l...t.2?..9....___,____,__ CONSTRUCTIONTiPE I PROT.CL UTORIES IBASM'TS YR.9UllT TOTALAREA OTl'lEROCCUPANCIES I AlOlNG IMPROvEMENTS ! H WIRING. YR I . ROOFING, YR: RlClHT EXPOSURE '" DISTJ'NCE I I I \ BURGlAR AlARM INSTALl-EO A1D SERVICeD BY ARE PROTECTION (SplifIk*,-, Jtaodptpe=., cO: (l-\a\Qfl Sy.tem,) i I LOCAL GONG SUBJECT OF INSUR..6JjC€ AMOUN2-~~INS % VALU.ATlON .. CA~SES Of LOSS~~~~'?t_DEDUcnBLE FORMS AND CONDITIONS TO APPLY ~ 'Loc #5 BuiTding$100, 000 80% RC Special $250-'NewCon'st 1997 ~T ~ I I I NO'Loc #6 Buitding$95;'oOO80%' RC-- Special-M$250'-riewconst 1999 ~) #7 BUitding$95, 000 80% RC Special 1999)/ I---- -$2'SO'-:NewCon'st (~~foi II All Frame '4 2 1 i-- PLUMBING, YR : HEAllNG, YR: ,-- OrNER LEFT EXPOSURE & DISTANCE , REAR EXPOSURE a. DISTANCE BURGLAR ALARM TYpe CERTlF1CA TE . EXPIRATION DATE nTENT GRADE CENTRAL STATION IGUARC~A~MEN Vv'fTHKEYS CLOCK HOURLY fiRE ALARM 1AAHUFACltJRER . CENTRAl STATION LOc.-.L. GONG , SEE NEXT PAWOR ADDITIONAL PREMISES, REPORTING FORM INFORMA TION, I~EMARKS, AND ADDITIONAL INTERESTS ACORD 14l).S (7/88) 1. lot 2 #927 ATTACH TO APPLICANT INFORMATION SECTION TLL €I ACORD CORPORATION 98 1 PR. E,MISES INFOR~ TION I ' SUBJECT OF 1N UAANCE '~T \-;-- ~ L I NO r I ~I G' NO, r AMOUNT COINS % VALUATION CAUSi:S ~~.~~S.__I~G~1J~3~uCnBLE r-:~~~ C~~~ TO APPl i L-- I --1;---~- ---------- ~ ---_._--~-----. I ADD1TloNAL COVERAGES RESTRl61-0N"S;-E:NOORSEMENTS AND R.A,'nNG -iNF;ORM~ -- - ~- -." CONSTRUCTION TYPE~\-- - - - _n-PR-oTcL-'STORIES 'BASM"TSuyR. BUll.r -fuTAI..AR1!.A - --- - OTHEfCoeCUPANCifs .-- - - --- -. ,~U":.O,"G I.PROVEME~---':=~. ~ PLUMBING, YR .-- ---. '-' -" - --- , WIRING. YR: HEATING. YR: ~-l ROOFING. VR ~ OTHER RiGHT EXPOSURE & DIS1A, ce --~LEFTEXP-OSURE&OISTANC~ - ,- -- ----REAR EXPOSliRE & OIS'TAJiCE-- --- .- SURGLARALARM TYPE ': - - '----CER~ACATE '~-EXPlAAn6N['ATE-- EXTENT 'GRADE 'CENTRAl".) N [ I --- WlTHKEYS ~GLAR ALARM INSTALLrO ANlfsERVlCEDBY-- ~- - - - --- - -- -- - - - - -- ------' - -'GuARDiiWA TCHMiN=- _ CLOCK HOURI.. FIRE PROTECTION (Sptin~\et1. Standpipes, CO-;- ~I'\ Sysi,;;;,r - ,- - --. - -- - -'. ~ - -ARE. AI..ARM M4NtJiiACTURER -.- - -=-._ CENTRAL STATI N LOCAL GONG VALUE REPORTING I~FORMA TION REPORTING FORM. PROvrot AVERAGE VALUES ~OR PAST 12 MONTHS SUBJECT OF INSURANCE' PReMISE f PREMISE 2 I MY OTHER LOCA- ~ nON DECl../I,~ED PREMISE J ATlNCEP110N ANY OTHER LOCA. PREMISES NQTOWNEO OR ACQUI 0 1\01-1 DECLARED AFTER INCEPTION p~EMISE UMIT AGGREGA. 'E: C ,~'--- OniER '1 I ---------- .-..- - ---- --- -- -- ---- ~ - - ~-- --- --_.~------_._.. ADD'TIONA~ INTEREsrS ; i NAME a. ADDRESS I ~' Superior Eank PSB N~ servicing\ Division , , i One RamlaJj1d Road ~ I Orangebur~, NY G I J NO.; Loc #1; 2; 4 I INtEREST \ Mortgagee : ~ KAMe &. A.~~S l ~ Fidelity lhrst Mortgage LLC NO, Its Successors o.lor Assigns ATlMA 11000 Bro~en Land Parkway, Ste #301 ~ Columbia, MD 21044 g I NO. Locs #4 & 5 INTEREST ( Mortgagee I REMARKS . \ . (Include fnfClTl)llllon On P4ll1iC.jpa~g Colrriers) 10962 : NAME & AOOllfSS ~ Rose Shanis Financial Services NO, Its Successors &Ior Assigns 26 Office Street Bel Air, MD 21014 L B L o G NO. Loc #6 & 7 INrEREsr--- Mortgagee x CERTIFfCATI REOUIREO x CERTlFICA lION REaUIREQ ~ NAME a. A.DDRESS ~ Commerce Bank NO. 100 Senate Avenue Camp Hill, FA 17011 S L o G NO. Loc #4 Only INTEREST 2nd Mortgagee x CER:llF1CATlO ReQUIRED x CER1IF1CATlON REQUIRED I i I I I ACORO 140-5 (7/88) ~ of 2 # 9 2 7 - , ,- HARTR PR~~:?~?~1. COMMERCIAL G:p~A~RAL LIABILITY SECTION . ~,.!I,j-"l)' 71') 591-B2BO_,__.~_f~~,' Hart Richard P.Jr. & Nancy J. . i " Named / AlA, Ine. I In$ur.d} 4550 Lena 'Drive Mechanicsdurg, PA 17055 OA TE 1M 100000j 031 110: EFFecTIVE DATE--exPIRATTo"NOAli--x - DrRE~~----PAYMENjpLAN I-l 02/25/01 o 21.:?S I 02' AGENCY a", COOE.: ~3g~8~ER 10: 206 S 3 COVERAGES LIMITS X: COMNERCIALGE EAALUABIUTY GENERAL AGGREGATE $ 2,000 ,000 pJ;lEMrU s _' CLAIMSMAO~ )C OCCURRENCE PROOU~-;-&~-;;-Em-o;E~;~sA~GA~-si:;oO'O",-_cL5o__ PREh\lSESlOPER,A. ONS _~I,. OWNER.,S....=+ON CTOR'S P~OTEC"\lE PERSONAl.. K. ADVERTISING INJUR.Y $ 1 , 000 , 000 . . EACH OCCURRENCE --. - - ---;-1~do-6-: 0"(56- - - f-:-.:: DE:OUCTlBLfS .~ FIRE DAMAGE (Anyone tir:J--3:O'.~- $15 () I e cfo-- -- PROOUCTS ~~ROPERTYDAMAq: S ___ _~~~~LEXPENSE(AnY(lI'J.per$'~~___._ ~ 5.'_000 ._=-- -=."-= ~ BODilY INJURY 1 !', _ ~ '2:w , i OCClJfl~!WC:( OTHER COVERAGES, fU::$.TJUCnONS AND/OR ENDORSEMENTS (For hlredlnon-o'M'led auto coveragel! attach the BIl5lneu Auto Section, ACORD 127) SUB CODE: u __ _~_____ 'OR COMPANY USE ONLY I AUOI F I OlHER '-0.00 TOTAL SCHEDULE OF HAZfRDS LOCATlON ' : CLASSIFICATION CLASS PREMIUM TERR r------_~lE ~ _ ___ __!REM1UM , CODE BASIS PREU/OPS PROOUCTS PREM/OPS P baUeTS 'C~~*l~~~;"~-~-~-- '~;;i; -~~/:;;O~ow'- --~_. __ iDWELLtNGS-ONE-FAMILY(LE &0i 010 SSOR" RtS1LQ~,'D _,.__ _ __ (PoO (0 _ ._.___~_ __,.. I AI?~rWlrN'" ___GOO/8_ ~L___~I~_____, _ ____ GOd /6 t.U 1 010 1 2. .3 If r : -_ _,_ _ _n~_~'~ _~~.LL _ _ .. bOOl1) k) 1 -~ _._~-----_. - -- -<-.- -- .--- bOO 16 LA.) ~ -~._--~------- I.f"ll{rt t)' t 010 b / 1. lV 010 010 ()kJ : I VAcA1 r LMn RAllNG AND PREMIUM BAst (S) GROSS SALES -PER Sl,otxuSAlES (P) PAYROLl- PER $1.OOOIP""V (A) AREA . PER 1 JXlOiSQ FT (e) TOTAL COST - PER $1.000ICQST (M)AOMISSIONS - PER 1,OOO/ADM fU) UNIT. PER UNIT (T) OTHER CLAIMS MADE (Explai aU "Yes" responses) 1. PROPOSED RETROAC IVE DATE: 2. ENTRY DATE INTO UNI TERRUPTED CLAIMS MADE COY: 3, HAS ANY PRODUCT." RK,ACCfDENT. OR LOCAflON BEEN EXCLUDED, UNIN URED OR SELF,-INSURED FRnM ANY PREVIOUS OVERAGE? 4. WAS TAIL COVERAGE URCHASEO UNDER ANY PREVIOUS POLICY? I \ I I \ ACORD 126-5 (3/93) 1 I () f 2 I TRANSITION 1. HAS THIS RISK OR ANY LOCATION NOT OUAlIFIED FOR TRA~SITION'? ES! NO , , !~ 2. IF THlS R1SK OUJ\,L!F1ES FOR TRANSITION. INDICATE THE YEAR Ii -----.X ffRSr QUALIfiED: AND: ~OCA TlON H_EW ~SS i::~X. PREVIOUS ~POSURE REMARKS x APPU.!=ABLE COVERJ GE PREMISES IPR LoueTS PREMlSES lPR DUCTS PREMISES IPR loUClS , PREMISES PR l.ICTS PREMIses JPR DveTS PREMlSES IPR( UCTS @ ACORD CORPORATIO 1993 JlR9q 'T'LT. , 'I CONTRACTORS ! . . , rXP!.Alf,AlL ~ESM RESP9NSES (for ~~~or~u~.~~~~tI_Qns!____ ___ ~___~S ~~~P.~~'~L_"Y_E~M ~~~PC?NS_:..SJ~~.!:)~"~~f.!:'.~...~_~~~ti~~~1________+~S' ~~ _~ '9~ES APPLICANT O~W PLA_N.~:P~~~~~l?~ ~~~l~~~~?_~_~~ 4. DO vOlA ~;U8CONTAACTORS CARRY COVERAGES'OR LIMITS -' r: ix 2. DO ANY OPERATIOW3: INCLUDE e\..AST\HG OR IJ1111iE OR STO'RE LESS THAN YOUAS7 " EX~lOS'VE MATERJAl7 -_.._-~_.- --------~-'---_.- ._--- 'X X 5. AR!:: SU6CONTRACTORS ALLOWED TO WORK WIO CERT OF INS? ; 00 ANY OPE~TION~lN~UJDE E~A~~-N~U~NEL1~ ---. ---- ----;-~OES ;~~~-l~~~; LEAS; ~Q;I;MENT -f'~ ~~~-ER~~~;OR i UNDERGROUND Vv'ORk OR EARTH MOVING? X VV1THQUT,OPERATQRS7 ,X REMARKSfO'E.SCR\6E ~E 1'1P'f ~WoR'\(, S\.iaCON'T'fUoc-reD - -~-' ---. % OF WORK SUaCQNTRACT'EO: , . FUl..l.. liME STAFF: , PARrnME: STAFF: I ------ .-,- , I I i PRODUCTSfCOMPLEl',ED OPERA TIONS I TIME" IN EXPEC'Tl::O PRINCIPAL COMPONEN :s _ PRODUCrS ~~NU~l ~~~~~_ _ _ _~ .O~_UN~____ _~}.~E1-- J.)f~__~___ _~~NDE~S~E_ __.._ -----._-- \ I ---r-----. - -- . --.-- _.----- --- .-- "~'-~--'._---'- -',-------- I ~_._~ ----. .. ----~--~.- --._--_.._--------.-._~. I f--- I ~----_.~._---- ----~-_._- ------ -.- ~----.-. EXP\...AIN Al..l "YES~ RESJ>O~fS ~O!~t~sl.5! p~!!e~roducf~P!.~tf~~_L _ _..!.e.!J!~~Pl.Al.N ALL "'Y~:S~ A~SPO~Ses IFOr lIny p.st_o..".E..rlI.!...~~pl'OdUct cw:~~r~~Il' y S NO 1. DOES APPl..lCANT INSTALL, SERVICE OR DEM01!STRATE PRODUCT~. ___X~. PRC?~TSB~~:E!~~INUE~_9:'ANGED7_ X 2_ FOREIGN pRODUCTS SbLD, QlSTRIBUTED, USED AS COMPONENTS.? X 7. PRODUCTS OF OTHERS SOLD OR RE,.PACKAGED UNDER I ---;--- --~ --- .-- -------- ~.- APPUCANT LABEL? 'X 3. RESEARCH AND DEVELOPMENT CONOUCTED OR N8/IJ -~--------~._._-. , PRODUCTS PLANNED? I X 8. PRODUCTS UNDER LABEl OF OTHERS? I iX 4. GUARANTEES. WARRA/'oITIES, HOLP ~ARMLESS AGREEMENrS? - --- X 9. VENDORS COVERAGE REQUIREO~_ _~ ~ I IX 5. PROOUCTS RELATED T~ AIRCRAFT~SPACE INDUSTR'y;- ---. - - 10. DOES ANY NAMED INSURED SelL TO OTH~~Q...I_.t!SUREDS? X PLEASE AT1ACH U~RATlJR~, BROCHURES:- LABELS, WARNINGS, ETC -.-. I I ADDITIONAL INTERESTs/CERTIFICA TE RECIPIENrS (Attach ACORD 45 fOr additional nam".) ~REST RANK: I NAME AND ADDRESS ~~~c~:._~,___ ~_.~~urRE~~_~~~~~N\!MBER !--------: ADCiTIONAL INSURED I lOCAl1~~ BUILD1NG: , - ~' lOSS PA'l'EE I IjEKIC~_.__ _._~T: ----.! MORTGAGEE I _ SCMEDUlED ITEM NUMBER: ( UENHOLCER I OiHER tJ E~PlOYEEASlESSo, i - --- ,-- ---.-. , ITEM DESCRIPTION: GENERAL INFORMATlO~ I EXPLAIN ALL wYES~ RESPQNS4S (For .11 p..t or pl"lIsolnt Q\18I'a.tlons\ YES NO exPLAIN All '"YES. RESPONSES (For all put Of (M"Uent Q~"l ,. YE ' NO 1. ANY MEDICAL FACILlTIEafROVIDI::O OR MEDICAL PROFESSIONALS ~~T!5W FACILITIES PROVIDeO? I 'v EMPLOYED OR CONTRA ED? X 10. 1$ mERE A SNlMMING POOL ON THE PREMISES? I iy 2. ANY EXPOSURE TO RAOI6AC"IVE!~CLEA~ IERlALS1__. ~ _ __ -X-----.!.!. SPORTlNG O!t SOCIAL EVENTS SPONSORED? 'v 3, DO/HAVE PAST. P8,ESEW'l oR DISCONTINUED OPERATIONS 12, ANY STRUCT!lRAL ALTERATIONS CONTEMPLATED? I ~ INVD"VE(D) STORING, fRtoATING, DISCHARGING, AP?L YING, ---~-.-- DISPOSING, OR TRANSPORTING OF H.A.ZAROOUS MATERtAL1 '\'3. p.,NY OEMCI.\1\ON EXPOSURE CONTEMPLATED? , (e.g". lendfllls, wastes, fuel ta~ks, etc) . -------.iL. 14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE. (No I I \ 4. ANY OPERATIONS SOLO, ~CQUIReD, OR DISCONTINUEO IN JOINT VENTUHES7 :1[, LASTS YEARS? : X 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? I '1[ \ _. I 5. MACHINERY OR EOUIPMs..,r LOANED OR RE.NTED TO OTHERS? J-i 16. IS THERE A lABOR INTERCHANGE INtTH ANY OTHER BUSINESS I l}. ANY WATERCRAFT, DOC~. FLOATS O\f\INED. H\RED OR LEASED? --X Oft SUBS1OlARlES7 I 'X 7, ANY PARKING fACILITIES bWNEDIRENTED? -----X-.:! 7. AftE OA Y CARE FACtUTIE.S O~ERA TEP OR CONTROLLED? :X 8. IS A FEE CHARGED FOR PfRK1NG? --"" REMARKS \ I I i ACORD 126..$ (3193)2 Of ? ilP.99 A rr ACH TO APPLICANTlNFORMA TlON SECTION SI!IMOBOVERlAYSPP 2047572 99 20041003 PAGE DATE: 1 OF 1 10/04"/200;1 NOTICE OF PAYMENT DUE AGENT: AMERICAN INS ADMN IHe PHONE: 717-591-8280 PA 000075 R HART ENTERPRISES INC 1200 ROSSMOYNE WAY MECHANICSBURG PA 17055 ACCOUNT # CB00162328 DESCRIPTION POLICY NUMBER LAST PAYMENT RECEIVED 06/25/2004 CURRENT DUE $2,024.84 DUE FROM PRIOR BILL POLICY: SPP 2047572 4,001.16 COMMERCIAL POLICY (02(25/2003 - 02/25J2004) SPP 2047572 02 05 V7 3,998.16 MINIMUM DUE 08/25/2004 $4,001.16 PAYMENT OPTIONS ! OPTION 1: PAY IN FULL I OPTION 2: PAY MINIMUM DUE OPTION 3: OTHER PAY $4,001.16 PAY $4,001.16 Not Applicable This will pay your account in fulL You will receive no further bills until your policy renews or i you make policy changes resulting in additional premium. We appreciate the opportunity to serve your insurance needs. Payment of amount less than minimum due may result in cancellation of policy. (If policy pre- viously terminated see Important Note on reverse side.) If a renewal policy, coverage expires on the due date if payment of minimum due is not received by the due date. ACCOUNT: CB00162328 AGENT: 00001913 NAME: R HART ENTERPRISES INC POLICY: SPP 2047572 DUE DATE MINIMUM DUE PAY IN FULL AMOUNT ENCLOSED 08/25/2004 $4,001.16 $4,001.16 PAYMENT Musr BE RECEIVED BY DUE DATE. 0000932001623280010000188000400116 I f you have questions concerning policy pay- ment status, please call the Payment Services Department at 1 - a 00- 444-9950, Ex\. 5118 Please see important message{s) on reverse side. PLEASE WRlrE ACCOUNT NUMBER ON YOUR CHECK AND RETURN WITH THIS STUB. MAKE CHECK PAYABLE TO AND MAIL TO: STATE AUTO INSURANCE COMPANIES P.O. BOX 182738, COLUMBUS, OH 43218-2738 000""" Pd..." >010"0< 01,OUO 070.:!'/~;; _~.!.'p if" ?!!JAX 480 4.~.Li.4 7L_.... _ ...f.1~lgBELL HIGHTOWER&ADAMS . . _!iii 006 VERIFICATION 1,---1Jnn CXC(;E!;y ,&(1in~ Co\lfr-/'()Y) 'Sp'(J(j.o~+ (title) ofST ATE AUTO INSURANCE COMPANIES, veritY that the statements made in the aforegoing docwnent are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C. S. 94904, relating to unsworn falsification to authorities. STATE AUTO INSURANCE COMPANIES BY;~~ . Title; ~i0K. ~llf(h\.JI-- Yf(l~ Dated: '7/00 los 31441 F,IUSERIST ACYlCCP COMPLAINTSIWORKISAIC31441. wpd, 101ulO5 TOTAL P.05 '" 0 0 ~, ,>:~ ,1 ~ w, .-1 '--- ',.- ~ r (-.> ~ [ ~ f"..' I>:' c::> ... -.; -0 <X) .. "- -.,) --:., "- \) '" " -' r:";j t: B ~~, -- C~~ v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2005-03889 STATE AUTO INSURANCE COMPANIES Plaintiff R. HART ENTERPRISES, INC. : CIVIL ACTION - LAW Defendant PRAECIPE TO REINSTATE COMPLAINT TO THE PROTHONOTARY: Please reinstate the Complaint filed to the above term and number and forward same to the Sheriff for service upon Defendant c/o: Richard Hart at 5154 KYLOCK ROAD, MECHANIC.BURG, CUMBERLAND COUNTY, PENN~~ /~ TO: Cumberland County ~ Prothonotary Robert D. Kodak Attorney for Plaintiff Attorney I.D. No. 18041 Dated: September 28. 2005 ---------- o s:; ,...., "'" ~ V' 1-n -':J c...) o L, ""::-. -:~::~ -0 ::;... ~ .-' :;r.:..,., rnc:-, ~~;I~(-j ;-':)'(~:'. .-,' ~\fA :'If, ~-< r;-? i" cJ-"'j - SHERIFF'S RETURN - NOT FOUND CASE NO: 2005-03889 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND STATE AUTO INSURANCE COMPANIES VS HART R ENTEREPRISES INC R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT R HART ENTERPRISES INC but was unable to locate Them in his bailiwick. He therefore returns the NOTI CE COMPLAINT , NOT FOUND , as to the within named DEFENDANT , R HART ENTERPRISES INC 1200 ROSMOYNE WAY MECHANICSBURG, PA 17055 ADDRESS PROVIDED IS NOT VALID IN CUMBERLAND COUNTY, POSSIBLE ALTERNATE OF: 1200 ROSSMOYNE ROAD IS A VACANT HOME. sheriff's Costs: Docketing Service NOT FOUND RETURN Surcharge 18.00 8.00 5.00 10.00 .00 41.00 _, -? _____r_ So a~~ ,/ ./~_ '<..I>' _:'=-...'.~, ..~_.~F-~.. L~-.,--.;;;;,~;:-:~ , ' R. Thomas Kline Sheriff of Cumberland County KNUPP, KODAK & IMBLUM 08/04/2005 Sworn and subscribed to before me q this day of ~ clon,;)- A.D. ~/A- ~_~. t~.,I. -' rothonotary v. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 05- 3 SS''i ~.J. -r:..- STATE AUTO INSURANCE COMPANIES Plaintiff R. HART ENTERPRISES, INC. Defendant(s) : CIVIL DIVISION, LAW NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney filing in writing with the Court your defenses or objections to the claims set froth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGffiLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION TWO LffiERTY AVENUE CARLISLE PA 17013 (717) 249-3166 TRUE COPY FROM RECORO III TIItImony wtlefeo1, I her. umo set my hand and Vl8 '!! of SilO ~ al CarIIlIII. PI. TlUlI, ~/ ~~ ~ ~'f': ~~ . (l.-j 51P',~~ ProtttonllMl"ff STATE AUTO INSURANCE COMPANIES Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 05- 3'889 ~( lL<- R. HART ENTERPRISES, INe. Defendant{s) CIVIL DIVISION ' LAW COMPLAINT The Plaintiff, STATE AUTO INSURANCE COMPANIES, by its attorneys, KNUPP, KODAK & IMBLUM, P.C., brings this action of Assumpsit against the Defendant to recover the sum of FOUR THOUSAND, ONE DOLLARS AND SIXTEEN CENTS ($4,001.l6), along with interest thereon from October 5,2004 upon a cause of action of which the following is a statement: I. The Plaintiff, ST ATE AUTO INSURANCE COMPANIES, is a company organized and existing under the laws of the State of Ohio, having its principal office and place of business at 518 East Broad Street, Columbus, Ohio 43215. 2. The Defendant, R. HART ENTERPRISES, INC. is a corporation organized and existing under the laws of the Commonwealth of Pennsylvania having and office and principal place of business at 1200 Rossmoyne Way, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On or about March 1,2001 Defendant did submit an Commercial Insurance Application to Plaintiff for purpose of obtaining insurance. A true and correct copy of said Application is hereto attached, marked Exhibit "A" and made a part hereof. 4. Subsequent thereto, Plaintiff did provide Commercial General Liability Insurance for the benefit of Defendant for the period of February 25, 2003 through February 25,2004. F:\USER\ST ACY\CCP COMPLAINTS\WORK\SAIC3 1441,wpd: IOJul05 2 5. The prices charged for said insurance coverages provided were just and reasonable, were the legal and market prices therefor, and were the prices which the Defendant promised and agreed to pay Plaintiff therefor. 6. Defendant defaulted on his obligation to pay Plaintiff the premiums when due. 7. The balance due and owing by Defendant to Plaintiff is the sum of Four Thousand, One Dollars and Sixteen Cents ($4,00Ll6), as appears by Plaintiffs Invoice hereto attached, marked as Exhibit "B" and made a part hereof. 8. Plaintiff frequently demanded payment from Defendant of said amount due and owing as aforesaid, but Defendant refused and neglected and still refuses and neglectd to pay said amount of any part thereof. WHEREFORE, Plaintiff brings this suit to recover from Defendant the sum of FOUR THOUSAND, ONE DOLLARS AND SIXTEEN CENTS ($4,001.16), along with interest thereon from October 5, 2004. Respectfully submitted, KNUPP, KODAK & IMBLUM, P.C. Robert D. Kodak 407 North Front Street Post Office Box # 11848 Hamsburg, PA 17108,1848 (717) 238-7151 Attorney ill No. 18041 Attorney for Plaintiff F:IUSERIST ACY\CCP COMPLAINTSIWORKISAIC31441. wpd: 10Ju105 3 , COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION PROc,CER -,PHONE '. . 7'~ "01' 82.8n CARRIER State Auto Insurance ,"OERWRITER l"'c,"o.~"), ,",1~ - " T d B ", . - Companies ,0 ergen AlA, Inc, -----.-, 45'50 L O' POUCIES OR PROGRAM REaUEsreo ~ma r~ve BINDER48276 Mechan~csb~rg, PA 17055 \ Producer: :Leon. Feinerman X ?ROPeRTf .___ INSTALLATlON/BUllOERSRISK _.~ VEHICLE SCHEOULt C.s~CQX '. Gt..J>,'5-r,:.NO S\C~ I" t\.E.CTR.ON\C QA.1"A PROC . BOILE.R & MACHINE . _ _ I -,..- n__ ~-~--~ .- ACCOUNTS RECENABlEl -- COMMERCIAl. -., COOl::' sua COOf: VAl,.UABLE PAPERS ,X GENERAL lIABILITY WORKERS COMPEN4ATlON AGENC'f CUSTOU.ER ID CRlME/MJ$CEllANEOUSCRME BUSINESS AuTO UMBREL1..A - TRANSPOIUATlONl MOTOR TRUCK CARGO ~ TRUCKERS PACKAGE POLICY INFORMATION DATE 1M'" ) 03/01 01 ACORD~ INDICATE SECT10NS AT1'ACHEO .:...X ~ EQUIPMENT FlOATER GARAGE ANO OEAl~S 20693 STA rus OF SUBMISiSION I QUOTE ENTER THIS INFORMAT1QNWHEN COMMO~ D~ATES A~~MS AF'?L ,!~~~!\AL L1NE~~.OR MONOLINE LlClES ) ISSUE POLICY ~ L BOUND (Give D:al~ ana/or Auach Copy) pROPOSED EFF DATE PROPOSED EXP OAre BILUI'lG PLAN PA'fMENTPLAH DATE I TIME A AM ...z_. DIP-eeT BI\..L l 02/25/01 ,12: 01 PM 02/25/01 02/25/0:; AGENCY"" Quarterly Iii APPLICANT INFOR TION Na~~I~AfiTVJr~p:k.~~~U~\c.~ \ .""___,,. _ ._--, R."" ,n'orpri M, 'no .j" . ,Cn En""" rOOE; -i'..1EO~;'i 17113 X INOfVIOUAL co;P~o;-~~~~~P-:;ER S~CORPO~TION --.-.--.- -=-~~QTFORP~T ---;EARSIN~USlNES~ PARTNERSHIP , JQINTVENTURE ORGANIZATION a=t= IHSPECTtONCONT.o..CT P~~E!f:.tt-'1_11 - 93 9 - 3'O~ '6 ---=-=-. t\CCOUN"nNGil,ECOR';)SCON.1"ACT .@:~io...!.!tl~=_=~ - Richard Hart C. ..J, H '*fL;Y Same - PREMISES INFOR ON AUDIT LOC. aLO' PART OCCUPIED STReeT, CITY, COuNTY, STATE., ZIP cooe CITY UMITS INTEREST YR BUILT 328L Swatara St. Steel ton -"- X' r;';;;;-'-:JC_-;;;;'~-'-1997100% Dauphin County, PA 17113 OUT$IOE TENANT 2 1 330, Swatara:'si::-si::eelto-n X INSIDE )( oWNER---1'997 100% ._-- Daufhin County, PA 17113 QUTS'O. "NAHT (See Attabhed Prerr'J.ses-Schedule:-T'---;;;;;;-;--- OWN'R ---- _. _.- 1 1 . OUTSIDE TENANT NA TUR" OF llUSlNE SlDESCRIPTION OF OPERATIONS BY PREMISE{S) G!:llERAL INFORMA ON e';PlAlH PoLL ~VE.s- RESP SES ,. IS THE APPLICANT A SUB$IDlARY OF ANOTHER ENTITY OR DOES lHE APPL1CAN'f HAve AN'( SUaSlOlARIES? 2. IS A FORMAl SAFETY PR RAM IN OPERATION? 3. ANY exPOSURE TO FLAM: LES. EXPLOSNES. CHEMICALS? REMARKS Home builded and remodeler YES NO EXPLAIN ALL .""ES" RESPQt(SES , : 4. ANY CATASTF!OPHe EXPOSURE? ; X ,S. ANY OTHER I1ISURANCE Wffil THIS COMPANY QR BEINGSU8MI'tiED7 ! X ~ 6. ANY POlICY ~ COVERAGE DeCLINED CANCElLED OR : i NON,-RENEWED DURING THE PRIOR 3 YEARS? I ES NO APPUCAN~S i StGNA1lJRE , ACORD 125 (3193) 1 of i 3 1340 PL L Iii ACORD CORPORA TIO 1993 lOC_ BlOII I, 3 4 5 6 7 ,1 PREMISES INFORMATION (Continued from page 1.) I 1~32 !watara St. Steelton, Swat~ra County, PA :418~420 Swatara St. Steelton, ,swatira County, PA 414 <1:atherine Street Steelton , Da~phin County, PA 17113 Srn.fET, CITY, COUNTY, STAre, z:.p COOL:: 1 1 1 1414 ,essamine Street , Da phin County, PA 1 '408 ,essamine Street I' Da' phin' County, PA I . , I I ! I , I CISGEM 125.4 (319313 or 3 # 13 40 Steel ton 17113 Steel ton 17113 'CITY UMITS INTER.EST X INSIDE X. OWNER , OOTSloe TENANT ,~ INSIDE X OWNER , OUTSIDE. TENANT x , INSIDE X OWNER OUTSIDE TENANT X INSIDE OUTSIDE X OVVNfR TENANT X INSIDE X OWNER OUTSIDE TENANT INSIDE OUTSIDe TENANT OWNER OUTSJOE INSIDe OWNER TENANT INSIDE OUTSIOE INSIDE OUTSIDE INSIDE OWSIDe INSIDE OUTSIDE INSIDE OUTSIDE INSIDE OUTSIOE INSIDE OUTSleE , INSIDE OIlTSIOE . ~INSIDE , OUTSIDE INSIDE ~ ; OllTSIDE '- INSIDE OUTSloe ; INSIDE --., OUTSIDE OWNER TENANT OWNER TENANT OWNER TENANT OWNER TENANT OWNER TENANT OWNER TENANT OWNER TENANT OWNER TENANT OWNER TENANT OWNER TE NANT OWNER . TENANT OWNER TENANT : YR BUILT ,1997 100% I 1997 100% 1997 100% 1999 100% 1999 100% PART O~C:UP!ED . .", , PRIOR CARRIER "fORMATION u"Ie CA~GO~Y 'fEARS:_9.8-=--D_L__ CARR"R I -----Pr,esqueJsle POliCY NUMBE;! DKF20115.1413 POLICYT(PE 1 ' e;.;;'_X~:V~II("C~ RETRO DATE YEARS: _...!~A!,~S:.__ __._ _ ._~ YEARS~____:~R~;._ ___ el-'NS ...O~ --l.-____ _____ ~ ()(.C"""t><l.l-...............~J!.l.l~~C~~f~ ~: :._~~._.. , ' ""'" I -"t2.I~ ~~. ..,.--.,-- .----- -~f-----.-!... .----'-.-------1---:- GENERAL AGGREGATE '2 00 o OJ) Q ~ODUCTS CO~P ijp---' 'j ->t_QO' j)~ ., -DD O~_'- AGGREGATE , 4.1._ -4_ __ P~RSONAL $. ~9v \NJ 1 I O...Q.O__O_QO EACH OCCURR1NCE 1,_0..0.1:)_,_0..0_0 _._ FORE DAMAGE , 100 Q eLO ,_ MEDICALEXPE~SE -5-,0.00- -~- POLICY NUMBER I POLICY TYPE L COMBINEO SINGt.E LIMIT BODILY ~,___ INJURY fA ACCIDENT PROPERT't' OAMAGf MODIFICATION FAG\OR TOTAl.. PREMIUM ,. G E N C E OR MA M L E L R, C A 'S A, LL , T y L , M , T S BQarL Y OCCuflRENCE INJURY AGG1eGA TE PRCPERlYOCC~RENCE OAMAGE AGG1EGATE c.OMaINEO SlNG11J: LIMIT MOD1F1CA TlON FAdrOR ..,--- 3 482 _.- -'-'-- -.- --- - -,-,_..,--- ,- -,- ,-- -,--..-----." - ,-- - ._'- -'--.-,..--- Presg:ue....l~l~ ._.______.__ _ _,_ _____.__._____ PKF?01I.51,4P_._ _ --.-. --- ,- ---,,-.- .-.--- _ -, Pack,~g~_n___ ___ .__ _________,____ Included EquiJ:2.....E.!-y__________ ____ _________ _", PKF201757413 Package =' =-=~- -,-- -- -.-.:-=-=-_-=--=.:-...:-=- -=-=- ==_-=-:::":= ,~==,-- LIMiT I MOD/FICA TIOt<. FACTtR TOTAL PREMIUM LOSS HISTORY E.NTER AU. ClAIMS OR ace RRENCES THAT MAY GIVe RISE TO CLAIMS FOR THE PRIOR 5 YEARS TOTAL PREMIUM CARRIER A L U I TA 0. M, OL ., I T 1 Y CARRIER P R o P E R T Y POLleY' NUMBER POlleY TYPE !!.LO : ~~~ AMT MQ01FlCAll0N FAG hR . TOTAL PREMIUM i T POliCY NUMBER I Included T1PEJDESCRJP110N OF OCCURRENCe: OR CLAIM OATE : OF CLAIM CHECK HERE IF NO!,!~.~ SEE.~~9.5SSU M~Y AltQUNT PAlO AMOUNT $1A.1'" RESERVED Al1JS ~ e~csitl ..~ a.O'1UI , ~. , ~=, , - , CIOUC .... -, REMARKS NOTE: FIOEUTY R"EE'WRES A AVe. YEAR \.05$ 'rIlSlORt I CARRIER POliCY TYPE DATE OF CCCURRf,NCE UNE , I IICORD125(J/9J)2of b H13"O \ I , I I I ~ ,- I ACORD~ rROPE~TY SECTION CLIENT# 20693 PROt'lUCER \. ~ APPUCAH'i {(~INilr.'ledrnSl,l'8dJ Hart I Richard P. Jr ~ AlA, Inc.. I JL..-.!i?rt EnterPr~L~.s=!1.,-:J:nci__,_ 455 C Lena D:a i v e i>f\OfoOSfD I:FF. OATe ._~~.~~~:~~._ ~~~!:?~~H . n..' Mechanicsburg, PA 17055 02/25/01 02/25/02 ,_..AGENCY '__________ ____Z-.E:REC~__ ~t5MPANy use' ONI. y HARTR OATE {MMIOOf'r'YJ 03/01/0 & Nancy. PA'{MElii P\JI~ I A\JOIT Quarter N PREMISES INFORMAT(ON , SUBJECT OF INSUR.!\NCE AMOUNT ; ;Loc #1 Bu~lding$95,OOO ~ i I N~'Lac #2 Bu lding$95,000 COINS "/oVALUATlO~~USes OF LOS~~~~~-g~ .-!!~UCll~l~____:9R~S AN~ co~~no~s TO APPLY 80% RC Special $250 New Canst 1997 1 \.. -----~-~---- ..- -" - --- ~ :Lac #3 Bu lding$95,OOO 80%,RC Special $250 New Canst 1997 \\ g !cantents J..1bOOO___RC _S~c~al__. __ _,,____' / NO. ,Lac #4 Bu:Ulding$105,000 80% RC Special $250 New Canst 1997-"j 1 I I AOOlTIONAlCOlJ'ERAGES,RE TRlC"ONS.ENOORSE"EN'TS.iNoM1iN~FOiWA.-ooH-"- b___. -. -.."- . --.-----.- .-- -~._. (",\ ($pO 'I 80% RC Special $250 New Canst 1997 CONSIRUCTlON TYPE n . - - PRor:c-L:1SfoR'iES-'aASM;:;:S-YR:BUILT'-TOTALAREA-- - OTHEROCCtJPANCIES-' All Frame " Q1...-- ---, -- BUILDING IMPROVEMENTS I ! WIRING. YR: 1 ~ ROOFING. 'fR.: ! RlGHTEXPOSURE.. DJSTANC PLUMBING. YR HEATING. YR: OTHER LEFT EXPOSURE & DISTANCE. .----. REAREXPOSURE&OI5TAACE BURGLAR ALARM TYPE CERTIFrcili--__.~~ --EXPiRATION OATE--- '-EXTE'Nr-GRAOE-~ENTRAl ST,A,110N 'MTH KEYS BURGLAR ALARM lNSiALLEO NO SERVICE-ODY -<- -- ---. j'(iUAROSN\ii1C-HMEN- -. CLOCK HOURLY FIRE PR01eCTIQN (Splinklllr~. Slandpipes. CCi-;-IH,lon SY$lem.!l~-~-- --iiRE- ALARM MANUFACTURER - -.. CENTRAL STATION ,- LOCAL GONG SUBJECT OF INSU~CE AMOUNT : 'Lac #5 Building$100, 000 ~ ' \ NO.1 Lac #6 Buitding$9S;-OOO -so% R;:;- Special ,- 2 . 1 i iLac #7 Bui~ding$95, 000 80% RC NO. I I 1 I I , . . ~ .....L.- AOOIT10NAL. COVERAGES, REsFnONS, ENDORSEMENTS AND RATING INFORMA nON All square fel"t is ap..E...roximately : l........l?.2..___, CONsTRUcnOHTYPE I PROT.CL ill$TORJES #BASM'TS YR,SUIL.T TOTAL.AREA I ~NG IMPROVEMENTS j --J ~IRING. YR: I t ROOFING, YR: RIGHT EXPOSURE .. DISTANCE 1 I I , C9INS"", ~.A~.. CA~S~ LOS5~~G~~f.OUC1I~_,~ FORM..~~ COND1710NS TO APPLY 80% RC Special $250 New Canst 1997 ) ( (') -$25o-:-Newcon'st 1999)/ ,--,-'--~'---' ---- $250 New Canst 1999 Special (.~fo?l/ OTHER OCCLJPANCIES All Frame '4 2 1 L--. PLUMBING, YR : HEAl1N.G. y~: r-- OTHER LEFT EXPOSURE & DISTANCE . REAR EXPOSURE & DISTANCE BURG!..AR ALARM TYPE CERnACATE II EJl,:PIRA110N DATE EXTENT GRAOE ceNlRAl STATION BURGLAR Al.A.RM INSTALLf!O A~O SERVICEO BY MGUAROSIWATCHMfN W1l}ll<EYS CL.OCK HOURLY RREpROT'EC1\OH (S~. ,tandplpels-.C~iHalonSy,t.m'l , f,~E ALARM JAAMUFAC'T\lRER . CENTRAL STATION' Loc.-L GONG SEE NEXT PAGe FOR ADDITIONAL PREMISES, REPORTING FORM INFORMA nON. I~EMARKS. AND ADDITIONAL INTERESTS ACOR014O:S(7/88) '1101 2 #927 ATTACHTOAPPLlCANTINFORMATIOIISECTlON TLL €) ACORD CORPORATlON 1988 PREMISES IN~ORM~TION SU6JECl OF \N URANCE AMOUNT COINS % VALUATION CAUSE:S OF lOSS 1~~1J~ DEDUCTIBLE ~ I=QRMS AND CONOlTlONS TO APPL -,_._- . --'--r--;'--'--: 11 " , NO. I i ~i NO, : I ADOITIONAL COVERAGES\ RESTRJC1,-ONs.-ENOOASE....ENTs ~'TiNG "INFORMA nON -- - -- --- CONSTRUCTION TYPE t--- - - - i '--- I . .-- PRor:- CL-' STORIES -; BASM"TS. "'iR. -BlllL-r -ToTAl.. ARf:A ~ OTHER- oCcUPAr.lC'ifs ._- - - -~.. -.-- SUILOING'MPROVEMENJ '---, , WIRING. YR: ----: ROOFING, YR 'RiGHT EXPOSURE & Dlsn CE , , Pt.UMS1NG. YR,: HEATING, YR: OTHER --, --CEF'TE.xf>O-SURE&CllSTA"NC~ - . - . -- ---'REAR EXPOSURE.. O!STANCE----. - BURGLAR ALARM TYPE -- --WllACATE /I EXPIRATION C'ATE-- ~ EXTENT GRADE . I _ _ _ CENTRAl STAT~)N BURGLAR ALARM INSTAl..l 0 ANO'SE-RViCecisy - -- - -- ---------.GUARDSIW'ATCHMEN WJn-IKEYS CLOCK HOURI.. FIRE PROTECTION (Sprin MS. SIUldptpe;: CO-;~n si&i&;;;"s)--'-- --. - - -. --.. -- -FIRE Ai:AAM MANUFACTURER I CeNTRAL STATI N -- LOCAL GONG VALUE REPORTING I~FORMA T10N REPORTING FOAM: PRovro~ AVERAGE VALUES ~OR PAST 12 MONTHS SUSJECTOF INSURANCE~ PREMISE 1 PREMISE 2 1 , ANY OTI'lER l.OCA. --- nONOECu.,RED PREMISE J ATINCEPllON ANY OTHER l.OCA. , TlON DECLARED AFTER INCEPTION PREMISES NOT OIIVNEO OR ACQUI 0 PREMISE UMIT AGGREGAtE OTHER -------.-..- --..-- .--- --.--.- - --------.-----.-.. ADDITIONAL INTEREsp-S : i NAME.. ADDRess l ~, Superior Eank PSB NO. Servicing I Division , , i One Ramla*d Road ~ i orangebur~, NY G [ J NO" Loc #1;2;4 t INlEREST I Mortgagee: ~ I NAME &. ADORESS \ ~. Fidelity ~irst Mortgage LLC NO.! Its Successors o.lor Assigns : 11000 Bro~en Land Parkway, ~ I Columbia, MD 21044 g I I NO. Locs #4 & ~ INTEREST I Mortgagee I x' CERTIFICATION REQUIRED , P NAME & AoonESS . E Rose Shanis Financial Services L " NO, Its Successors o.lor Assigns 26 Office Street B Bel Air, MD 21014 L 0 G NO. Loc #6 & 7 TNTE.REsr-~- CERTIFrCA TI ~ Mortgagee X REQUIRED P NAMI;." ADORESS R E Commerce Bank " NO. 100 Senate Avenue Camp Hill, PA 17011 B L 0 G NO. Loc #4 Only INTEREST 2nd Mortgagee X CERllFICAlIO REOUIREC 10962 ATIMA Ste #301 X CERTIFICATION REQUIRED REMARKS ' I fll'\dudilllnlOfTlllll1on 00 PartiC.ipa~g earners) I I I I I ACORD 140-5 (7/881 ~ of 2 # 927 - l H RTR COMMERCIAL GENERAL LIABILITY SECTION ACORD, 59i-8280 DA TE (M 100IYY1 03/ 1/0: PROO~CER I PHONE.J ~ , 717 . ~J~"'I~),---_ . AlA, . Inc. i 4550 Lena 'Drive Mechanicstiurg, PA APPUCANT {Flnl . Hart, N~rned In$lJ(.dJ Richard P. Jr. & Nancy J. 17055 EFFe:cTiVEi)A:re--EiPJAAnON DATE--X. DlReCT61lL ~ 02/25/01 02/,25/02' 1 AGENCY BILL PAYMENT PLAN I AUOI ~ I COQE: ~U~~OZERJO: 206 3 COVERAGES X : COMME.RCIA.L GE EAAL UABIUTY I CLAIMS MAO~ X- OCCURRENCE -p"ER'S~CO"i=R'SPRO"'C'W~___ . oeCUCTIBl...ES ~ PROPERTY DAMAq: 1 SOOIL Y INJURY 1 SUB COOE: ~.. ------- 'OR COMPANY USE ONt Y LIMITS GENERALAGGREGArE $ 2 , 000, 000 ~~~~-&~~ ;'.~~~'~;E~~~~~;G;;G~$ 2-; 060 -,- d 6 0- PERSONAL & AO\lE;;;;;\~Y---' $ 1 , 000 I 000 EACH OCCURRENCE -_.- ----;-Cocfo; 6046- ARE DAMAGE {Any OI'M IlrlJ ~B":~ ~I1fo~l.f5o- -- _!,,':.?~AI.EXPENSE(A.nY~~.cm.L_____ ~ 5,.000 -=- -=-"-=:.= PREMILJ S PREMISESJOPER./l. ONS PROOUC~ $ ~. ,~. ". $ oce~"fN<:! OTHER COVERAGES, FlE~TRlCTIONS AND/OR ENDORSEMENTS (For hj,.dlnol1..owt'l,d .Juto c:o;.tagn attac;h th_ e~,lneu Auto Section, ACORD 127) OiliER 0.00 TOTAL SCHEDULE OF HA RDS LOCI.. nON . CLASSIFICATION RATE PREMIUM TERR r-----.----- . PREU./OPS PRODUCTS PRE!lI/OPS -~_..._'-~'---'-- p) /.0,0 '010 ' ~) J ' l.1j.1. % ' 1 CLASS CODE : CARPEUTRy'-------- 91342 A plM,t It1t?JL. (.O(J 10 iDWELLtNGS-ONE-FAMILY(LE PREMIUM BASIS P DUCTS 2- ,SSOR' RI,SlLQlikY2 _,__ (;,00(0 - - - -- -- -.-- - -- --- .3 I ~11'~ h-.., "-,.,. r; "0 It! ~L 010 . -- --- -______0__- ---.-- If , GOd 10 t.01 010 , -- .-----. -. .----_.- --- -----" r i GOo 10 4JL 010 , -_. '--' -.-..--------" .-----.-.---.---.- -_.--- b , bOOID t.tH 010 ./ -.-------- - -- ------.- / , bOO 16 lAH 010 ~ V Ac A? --.--------- ..--.---.- 1- , l' LMKJ <f"lf.{r{ t)' t dft) , I - ! ! I -, , , , , I I I I ._-- - fl.A l1HG AND PREMIUM BAS(s ($) GROSS SALES. PER $1.~SAlES (A.) AREA. PER 1,000150 FT (!.II ADMISSIONS - PER 1.OC(llADM mOTHER (P) PAYROLL. PER $',OOOIP~Y (C) TOTAL COST. PER Sl,OOOICOST (U) UNIT. PER UNIT CLAIMS MADE (Explai 811 "Yes" responses) TRANSfTlON ,. PROPOSED RETROAC IVE DATE: --- 1. HAS THIS RISK CR ANY LOCATION NOT QUAUFIED FOR ES! NO 2. ENTRY DATE lNTO UNI~ERRUPTED CLAIMS MADE COV: TRANSITION? , , 3. HAS ANY PROOUCT.I'o\l-RK. ACCIDENT. OR LOCATION .!~ 2, IF THIS RISK OUAl.lfIES FOR TRANSITION, INDICATE THE YEAR rr ~~~~ exCLUDED, UN~~URED OR SELF,-INSURED FR M ANY PREVIOUS OVERAGE? X FIRSr aUAlIFIED: AND: 4. WAS TAil COVERAG~URCHASED UNDER ANY ':-OCATION NEW ClASS i~R.' PREVIOUS EXPOSURE APPUCABLe COVEg, GE PREVlaUS POLICY? I X , : , mUCTS PREMISES PR R'iMARKS \ PREMISES IPR DUCTS , PREMISES IPR ~UCTS I I I"" I PREMISES UC,. I ! , PREMISES !"" UC,. , I"", , PREMISES UC,. :ACORD 126-5 (3193) 11 ~ f 2 Jl~9q '1"LT, @ ACORD CORPORATJO 1993 I CONTRACTORS rXPLAILALl ..,es. RESP NSES (fo.. .?~~or~.~.~~~~d.on"!_.__ ___ ~_~S NO eXpL,AIP>....LL .YES. RESPONses (I"Qf" pa"l or pr...rll oJWl'''dOf'.J _!~~OES APPLICANT O~W PLA_N~:E~~~~~9~ ~~~1~~Tl0~S7 .X-;; DO ;O~/~- ~~~CO~TRAC';OR.~-C~;~;;O~ERAG-ESC;~-Z;~~S 2, DO A"Y OPERATION~ INCLUDE BlASTING OR UTIliZE OR STORE _lESSTHAN YOURS~,,______,__.,_ ..,__ EXPLOSIVE MATERIAL:? X ' 5. ARE SU~~~?~TRACTOR~ ~lLOvyED Tg__~!3~_W/C?_~~~.I..OF INS? ~ DO ANY OPEAAT10NJ~E EXCAVATION, TUNNELING, 6. DOES APPLICANT LEASE EQUIPMENT TO QTHERS'MTH OR UNDERGROUND mRI< OR EARTH MOV!NG? X WlTHOUT,OPERATORS? REMARI(S/DESCRlse THE 'NPE OF WORK SUaCONmACiED , % OF WORK SUBCONTRACTED: . . FULL TIME STAFF: . PARr TIME STAFF: I I I I I PRODUCTS/COMPLETED OPERA TIONS I A T1....e IN EXPECTED _ PRODUCTS _r~NU~l~~~~~_ __ ~~.o~_UN~_._ _J~~J.,l.FJl.______~TENDE~.~~__.._. I PRINCIPAL COMpONEN ---...--- -~._- ---., - _._---_._._--_._--_._-._--~. I I fXPl,AIN A.Ll ~YES~ RESpON~ES IFo!~t~,t~ ~~!!.nl pl"~t or opertatl.~~_ _ ~~~~~N ALL ...,~S~ RE.SPONSES {For '1"Y pa't_~.~!~~':l" ..2~r~~~ 1. DOES APPLICANT INSTAll. SERVICE OR OEMO~STAATE PROOUCT~. __ _X 2. PRC?OUCTS B~D, OISCO~~~NGED?_ . 2. FOREIGN PROQUCTS Sbl.O, OtSTRI8UTEQ, USED AS COMPONENTS7 . X 7. PRODUCTS OF OTHERS SOLD OR RE,.PAC'AAGED UNDER 3. RESEARCH AND DEVElOPME;T CONDUCTED O~-~~- --'--' --- _ APPU~~.~~__. _._ >_. PROOUCTS PLANNED? I X a. PRODUCTS UNDER LABEl. OF OTHERS? 4. GUARANTEES, WARRA/' TIES, HO'.LD HARMLESS AGR~_EME~J7 ~ -' X 9. VENDORS COVERAGE REQUIRED.~______ 5. PRODUCTS REIJ\TEO T AIRCRAF~PACE INDUST.!!r?.- __ ._, 10. DOES ANY ~ED INSURED SELL TO OTHER NAMED I~SUREDS? PLEASE A.TTACH UTERATUR " BROCHURES, l..A.8El.S, WARNINGS, ETe ADDITIONAL INTERESn,/CERTIFICA TE RECIPIENTS (Attach ACORD 45 for additional nam...) ~REST RANK; i NAME AND ADDRESS REF~~C~:.______ __.~~~IRE.E:-_~TERESTINlTE~N~f.lBER r-J ACClTIONAL1NSUREO : ~CAlTON: _ BUILDING: , , ~, LOSS PA.YEE 1 ----.! MORTGAGEE I W UENHOl.CER ! D,. EMPLOYEE AS LESSOR: I I ITEM DESCRIPTION: GENERAL INFORMA T10~ EXPLAIN AU. MYES" RESPOI.IS4S (Foe.1I put Of I)(...nt operatlonsl VEH'C~ __. __BOAT: SCHEOULEC ITEM NUMBER: Oni ER YES NO ExPL.AlN A.Ll "YES. RESPONSES (FOl" allllutorpRSentop&faUonll 1. ANY MECICAL FACILITIES PROVIDED OR MEDICAL PROFeSSIONALS 9. RECREATION FACIUTlES PROVIDED? EMPLOYED OR CONTRAdrED? X 10. IS THERE A SMMMING POOL ON THE PREMISES? 2. ANY EXPOSURE TO RADlbACTfVEiNUCLEAR MA~RlAlS?___ __.--.X--.l1. SPORTING O!t SOCIAL EVENTS SPONSORED? 3, OOJHAVE PAST, PRESENl OR DISCONTINUED OPERATIONS 12. ANY STRUCTURAl ALTERATIONS CONTEMPLATED? INVOlVE(D) STORING, TR~TING. DISCHARGING, APPLYING. ' DISPOSING. OR TRANSPORTING OF HAZARDOUS MATERIAL? 1'3. ANY DEMOlll'lON EXPOSURE CONTEMP\.ATED7 fe.c. landfillS, wastes. ruel ta~k5. elcl --.X.- 14. HAS APPUCANT BEEN ACTIVE. IN OR IS CURRENTLY ACTIVE IN 4. ANY OPERATIONS SOLD, ~CQUJRED. OR DISCONTINUED IN JOINT VENTURES? LAST 5 YEARS? . I _. 5. MACHINERY OR EQUIPM~T lOANED OR RENTED TO OTHERS? 6. ANYWATERCAAFT, DOC'I6:;. FLOATS OWNED. HIRED OR LEAsED? 7. ANY PARKING FACILITIES OWNED/RENTED? 8. IS A FEE CHARGED FOR P~RKING? REMARKS 1 \ x . 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? ~ 16. IS THERE A l..A.BOR INTERCHANGe v...TH ANY OTHER BUSINESS ----X OR SUBSIDIARIES? ~7. ARE OAY CARE FACILITIES OPERATED OR CONTROlLED? -X I I i ACORD 126-8 (3193) 2 rJ 2 11899 AITACH TO APPLICANT INFORMATION SECTION YES.' NO !X 'X [ 'X S NO X i , IX [ iX I iX X , YE ,NQ I 'v I 'v 'v \'1' Iv I :'1', 'v , I I v 1( SIIIMOBOVERLAYSPP 2047572 9920041003 PAGE DATE: 1 OF 10/0:,\/20Q4 1 NOTICE OF PAYMENT DUE AGENT: AMERICAN INS ADMN INC PHONE: 717-591.8280 PA 000075 R HART ENTERPRISES INC 1200 ROSSMOYNE WAY MECHANICSBURG PA 17055 ACCOUNT # CB00162328 DESCRIPTION POLICY NUMBER LAST PAYMENT RECEIVED 06/25/2004 CURRENT DUE $2,024.84 DUE FROM PRIOR BILL POLICY: SPP 2047572 4,001.16 COMMERCIAL POLICY (02/25/2003 ' 02/25/2004) SPP 2047572 02 05 V7 3,998.16 MINIMUM DUE 08/25/2004 $4.001.16 PAYMENT OPTIONS I i OPTION 1 : PAY IN FULL OPTION 2: PAY MINIMUM DUE OPTION 3: OTHER r PAY $4,001.16 PAY $4,001.16 Not Applicable This will pay your account in full. You will receive no further bills until your policy renews or you make policy changes , resulting in additional premium. We appreciate the opportunity to serve your insurance needs. Payment of amount less than minimum due may result in cancellation of policy. (If policy pre- viously terminated see Important Note on reverse side.) If a renewal policy, coverage expires on the due date if payment of minimum due is not received by the due date. ACCOUNT: CB00162328 AGENT: 00001913 NAME: R HART ENTERPRISES INC POLICY: SPP 2047572 DUE DATE MINIMUM DUE PAY IN FULL AMOUNT ENCLOSED 08/25/2004 $4,001.16 $4,001.16 PAYMENT MUST BE RECEIVED BY DUE DATE. 0000932001623280010000188000400116 If you have questions concerning policy pay- ment status, please call the Payment Services Department at 1 - 8 00- 444.9950, Ext.5118 ;;;(:#!,e7'~~f,9,\~1ff~~~.'" Please see important message(s) on reverse side. PLEASE WRITE ACCOUNT NUMBER ON YOUR CHECK AND RETURN WITH THIS STUB. MAKE CHECK PAYABLE TO AND MAIL TO: STATE AUTO INSURANCE COMPANIES P.O. BOX 182738, COLUMBUS, QH 43218-2738 ~ooo?S ~"n'.' ,.,..,.. .".7". 07.;T}/9~_.iI'S:!? 1..2" ~2JAX 480 4.~.LI.47.L_.... _ ...f~~gBELL HIGHTOIVER&ADAMS . ._~006 VERIFICATION I, -An n ex 001./ {"",,'I ( , Set',' 1)<< CtJ\lf('f10Yl ~rjl1.jJ.A~+ Hille) ofST ATE AUTO INSURANCE COMPANIES, verify that the statements made in the aforegoing document are true and correct. [understand that false statements herein are made subject 10 the penalties of 18 Pa. C. S. g4904, relating to unsworn falsification to authorities. STATE AUTO INSURANCE COMPANIES By: ~J~ . Title; ~10lZ ~11f(hV1- Yf(I'~ Dated: f-} /00 IDS . 3t441 F,IUSERIST ACYlCCP COMPLAlNTSIWORKISAIC31441. wpd, lOJulOS TOTAL P.06 SHERIFF'S RETURN - REGULAR CASE NO: 2005-03889 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND STATE AUTO INSURANCE COMPANIES VS HART R ENTEREPRISES INC CPL TREVOR KENT Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon R HART ENTERPRISES INC the DEFENDANT , at 1749:00 HOURS, on the 4th day of October 2005 at 5154 KYLOCK ROAD MECHANICSBURG, PA 17055 by handing to RICH HART, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Postage Surcharge 18.00 13 .44 .37 10.00 .00 41.81 So Answers: .~~~~ R. Thomas Kline 10/05/2005 KNUPP KODAK IMBLUM '" .2iJ - By: ~L.J- (" Deputy Sheriff Sworn and Subscribed to before me this day of (j) A.D. STATE AUTO INSURANCE COMPANIES Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTI, PENNSYLVANIA v, : NO. 2005-03889 CIVIL R. HART ENTERPRISES, INC. Oefendant(s) : CIVIL DIVISION - LAW TO: PROTHONOTARY, COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRAECIPE FOR DEFAULT JUDGMENT Enter judgment in favor of Plaintiff and against Defendant( s) R. HART ENTERPRISES, INC., named for failure to file within the required time an Answer to the Complaint in the above- captioned case and assess the Plaintiffs damages as follows: Amount claimed in Plaintiffs Complaint $4,001.16 Interest from October 5, 2004 at the statutory rate of 6% per annum $295.10 Total $4,296.26 It is hereby certified that a written notice of intention to file this Praecipe was mailed to the Defendant(s) and his attorney of record, after the default occurred and at least ten (10) days prior to the date of the filing of this Praecipe. See Exhibits A & B attached. ,.? ~BLUM'P.C. ~\DS DATED: I d-~ Judgment entered and damages assessed as above. CV~~ Pr6thonotary .. Robert D. Kodak, Attorney for Plaintiff Robert L. Knupp Robert D. Kodak Gary J.lmblum lAW OFFICES OF KNUPP, KODAK & IMBLUM, P.C. CAMERON MANSION 407 NORTH FRONT STREET POST OFFICE BOX 11848 HARRISBURG, PA 17108.1848 Telephone: 717/238,7159 Facsimile: 717/238,7158 email: kki.law@verizon.nel F I. L~ F f%t.1..O EU.:nupp _ liO:ifo9,(976) Robert H. Maurer (1923,1998) November 9, 2005 R HART ENTERPRISES INC 5154 KYLOCK ROAD MECHANICSBURG PA 17055 RE: State Auto Insurance Companies VS: R. Hart Enterprises, Inc. No. 2005-03889 Civil, Court of Common Pleas Cumberland County, Commonwealth of Pennsylvania Our File No. 31441 Greetings: In accordance with Pennsylvania Rules of Civil Procedure 237.1 (a)(2), we are enclosing herewith a Notice of a Praecipe for Entry of Default Judgment. According to the records as they are found in the Office of the Prothonotary of Cumberland County, you have not filed responsive pleadings to the Complaint filed against you to the above term and number, nor has any attorney entered an appearance on your behalf. Accordingly, we are forwarding to you the enclosed Notice which indicates that if you do not take action as set forth in this Notice, we, at the expiration of time indicated therein, will request the Office of the Prothonotary of Cumberland County to enter Judgment against you in the amount as set forth in said Complaint. Very truly yours, KNUPP, KODAK & IMBLUM, P.C. Robert D. Kodak, Esq. RDKlkqb enclosure cc: ATTN AIDA HUST CAMPBELL HIGHTOWER & 4645 S LAKESHORE DRIV TEMPE AZ 85282-7127 #75023 I EXHIBIT A ',LE Gapy STATE AUTO INSURANCE COMPANIES Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYL VANIA v, : NO, 2005-03889 R. HART ENTERPRISES, INC. Defendant(s) : CML DMSION ' LAW IMPORTANT NOTICE TO: R. HART ENTERPRISES, INe , Defendant(s) DATE OF NOTICE: NOVEMBER 9,2005 YOU ARE IN DEF AUL T BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOu. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAYBE ENTERED AGAINST YOU WITHOUT A HEARING, AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORT ANT RIGHTS, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE ALA WYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIA nON TWO LIBERTY A VENUE CARLISLE PA 17013 (717) 249-3166 EXHIBIT I B G ;:::) p ..{,O. .....a ~ \t.. ~ 0 r-> \; (' C) .0 ~~',:.;;.' r c c: ~~ ~'i1 1.:)'1 .j C) ..-< - r-rt wJ: -r'1 ~ ~ " flIC. ~.,.., \~,- ' j ,...0 r ~,) ,;,~y ""Q c;J ,~(: QS ~ C> -,.~ -t.. f: -_.> "'~ (j ~ '":" r:-:"> =:.~~\"(" (\ :;.~ \' -L r".~ Ci ."- - --_._.._~---------- " " . STATE AUTO INSURANCE COMPANIES Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNlY, PENNSYLVANIA v, : NO. 2005-03889 CML R. HART ENTERPRISES, INe. Defendant( s) : CIVIL DMSION - LAW TO: R. HART ENTERPRISES. mc. , Defendant(s) You are hereby notified that on -=Uf.. L ,,),j (Judgment) has been entered against you in the above-captioned case. , 20~ the following Judgment entered in the amount of $4.296.26. DATE /)FL elF. J.coS . I hereby certifY that the name and address of the proper person(s) to receive this notice is: R HART ENTERPRISES mc 5154 KYLOCK ROAD MECHANICSBURG PA 17055 N R. HART ENTERPRISES. me., Defendido/a Defendidos/as Por este medio se Ie esta notificando que el de del 2005, ellla siguiente(Fallo) ha sido anotado en contra suya en el caso mencionado en el epigrafe. FECHA: Protonotario Certificao que la siguiente direccion es la del defendido/a segun indicada en el cetificado de residencia: R HART ENTERPRISES mc 5154 KYLOCK ROAD MECHANICSBURG PA 17055 Abogado del Demandante , STATE AUTO INSURANCE COMPANIES Plaintiff V. R HART ENTERPRISES, INC. Defendant TO THE PROTHONOTARY: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2005-03889 CIVIL DIVISION - LAW PRAECIPE Please mark the above-captioned Judgment as settled and satisfied in full. TO: Cumberland County Prothonotary Dated: March 15. 2006 - Robert D. Kodak Attorney 1.0. No. 18041 Attorney for Plai ntiff 31441 g ? -00; \:!i0, ~-:" 7~ VO'~ ~. Gt-: lt~ :.=:2 :;:i. ~ :It p> ?;) - 0' -0 .... - ~ ~:n -o~ -9Y \_)tr'~) ~'c :t~ ;;:;l-) _;0:--)ln ~l <p -< <-!? N ..0 SHERIFF'S RETURN - GARNISHEE CASE NO: 2005-03889 P COMMONWEALTH OF PENNSLYVANIA COUNTY OF CUMBERLAND STATE AUTO INSURANCE COMPANIES VS HART R ENTEREPRISES INC And now SHARON LANTZ ,Sheriff or Deputy Sheriff of Cumberland County of Pennsylvania, who being duly sworn according to law, at 0010:00 Hours, on the 1st day of March , 2006, attached as herein commanded all goods, chattels, rights, debts, credits, and moneys of the within named DEFENDANT R HART ENTERPRISES INC , in the hands, possession, or control of the within named Garnishee 5154 KEYLOCK ROAD MECHANICSBURG, PA 17055 Cumberland County, Pennsylvania, by handing to CONNIE DEZINSKI (MANAGER) personally three copies of interogatories together with 3 true and attested copies of the within WRIT OF EXECUTION and made the contents there of known to Her . Sheriff's Costs: Docketing Service Affidavit Surcharge .00 .00 .00 .00 .00 .00 So a~: v4 ~ ".l~e~ R. Thomas Kli e Sheriff of Cumberland County 03/10/2006 Sworn and subscribed to before me this :2 'I fi! day of ~ {ic'/. A~D', by, Pr honota Thomas Kline, Sheriff, who being duly sworn according to law, states this writ is returned STAYED. ' Docketing Poundage Advertising Law Library Prothonotary Mileage Surcharge Levy Certified Mail Post Pone Sale Garnishee Postage TOTAL $ 18.00 51.91 Advance Costs: 150.00 Sheriffs Costs: 144.81 $ 5.19 Sheriff s Costs: .50 1.00 4.40 40.00 20.00 Refunded to Atty on 03/1 0/06 9.00 144.81 2006 A.D. So Answers; ?""~ M~~~ R. Thomas Kline, Sheriff CJ ~\'JL- \3,~M By Claudia A. Brewbaker ~ v, IN ""T t>J -....0 Sworn and Subscribed to before me E S :b "i/ ilZ 93.:1 QOOl ~~~:i:lff)) Vd 'AlhIIOJ ONv'iU::l8WnO ,j,jICJ3HS 3Hl jO 301.:J.:J0 ~~\~~\~\ I.sD <.'.k...6'3.) %'0 10-/7r-12-& WRIT OF EXECUTION and/or ATTACHMENT COMMONWEALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND) NO 05-3889 Civil CIVIL ACTION - LAW TO THE SHERIFF OF CUMBERLAND COUNTY: To satisfy the debt, interest and costs due STATE AUTO INSURANCE COMPANIES, Plaintiff (0) From R. HART ENTERPRISES, INC., 5154 KEYLOCK ROAD, MECHANICSBURG, P A 17055 (I) You are directed to levy upon the property of the defendant (o)and to sell LEVY UPON ANY PERSONAL PROPERTY OF ABOVE-LISTED DEFENDANT(S) AT THE ABOVE ADDRESS. (2) You are also directed to attach the property of the defendant(s) not levied upon in Ihe possession of COMMERCE BANK, 64 ASHLAND AVENUE, CARLISLE, PA 17013 - ANY ACCOUNTS UNDER DEFENDANT'S NAME(S) AND/OR ACCOUNT # 031301846 536000664 GARNISHEE(S) as follows: and to notify the garnishee(s) that: (a) an attaclunent has been issued; (b) the garnishee(s) is enjoined from paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant (s) or otherwise disposing thereof; (3) Ifproperty of the defendant(s) not levied upon an subject to attaclunent is found in the possession of anyone other than a named garnishee, you are directed to notify himlher that he/she has been added as a garnishee and is enjoined as above stated. Amount Due $4,296.26 Interest FROM DATE OF JUDG. (12/28/05) Arty's Carom % $214.81 Arty Paid $165.31 Plaintiff Paid Date: FEBRUARY 17, 2006 L.L. $.50 Due Prothy $1.00 Other Costs CURTIS R. LONG ' (Seal) Prothonotary ~ 'l!Y: ~fl4 'L. .P. J2".1J Deputy / REQUESTING PARTY: Name ROBERT D. KODAK, ESQUIRE Address: PO BOX 11848 HARRISBURG, PA 17108 Attorney for: PLAINTIFF Telephone: 717-238,7159 Supreme Court ID No. 18041 . ' . STATE AUTO INSURANCE COMPANIES IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PLAINTIFF V. NO. 2005-03889 CIVIL R. HART ENTERPRISES, INC. : CIVIL DIVISION - LAW DEFENDANT: V. COMMERCE BANK GARNISHEE PRAECIPE TO THE PROTHONOTARY: Please mark the above-captioned Judgment as settled and satisfied in full AS TO GARNISHEE. COMMERCE BANK. ONLY. TO: Cumberland County Prothonotary Dated: June 8. 2006 ~ Robert D. Kodak Attomey I.D. No. 18041 Attorney for Plaintiff 31441 1f l ~ h () - ~ 0 ...{ Iv ~ -.0 - ,t5 -.c::- t i:: ~ --.:(- o C :i::;. "-' i~ = "'" CJ 'Tl ...., III m-- r- ~F; " ' L. c:: :Ie I 1.0 -"'!j ::'J: ~~, Z ~i~: c' -<