HomeMy WebLinkAbout06-2065
ROBERT L. MILLER, as Administrator of
EST ATE OF ERIC BISHOP, Deceased,
COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
Plaintiff
CIVIL ACTION - LA We .L'---r;:=:~
NO. Ob - ~Dc:.~ Il,H I tt"-'""\,
v.
DARRYL NEVIUS,
PETITION FOR APPROVAL OF
WRONGFUL DEA TH/SURVIV AL
ACTION SETTLEMENT PURSUANT
TO Pa.R.C.P. 2206
Defendant
PETITION FOR APPROVAL OF DECEDENT'S COMPROMISE SETTLEMENT
AND DISTRIBUTION OF PROCEEDS PURSUANT TO PA. R.c.P. 2206
Petitioner, Robert 1. Miller, as Administrator of the Estate of Eric Bishop, deceased, by
and through his attorneys, Navitsky, Olson & Wisneski LLP, hereby avers as follows:
I. Petitioner, Robert 1. Miller, is the Administrator of the Estate of Eric Bishop by
virtue of Letters of Administration duly granted by the Register of Wills of Cumberland County,
Pennsylvania on or about September 8. 2005. A copy of the Certificate of Grant of Letters of
Administration is attached hereto as Exhibit "A".
2. Petitioner, Robert 1. Miller, is the brother of the decedent. Eric Bishop.
3. On or about, July 12. 2005, Eric Bishop was involved in an automobile accidenl
that took place on the Carlisle Pike in Cumberland County, Pennsylvania. A copy of the police
accident report is attached hereto as Exhibit "BOO.
4. Eric Bishop died as a result of the injuries that he sustained in the accident. A
copy of the Death Certificate for Eric Bishop is attached hereto as Exhibit "Coo.
5. Petitioner, Robert 1. Miller, in his capacity as Administrator of the Estate of Eric
Bishop, has asserted a Wrongful Death and Survival Claims against Darryl Nevius for the
i'!iuries arising out of the aforesaid accident.
'.
.
6. Defendant, Darryl Nevius, by and through his insurance carner, Westfield
Insurance, has agreed to compromise the claims of the Estate of Eric Bishop for his per-person
automobile insurance policy limits of Fifty Thousand ($50,000.00) Dollars. See, certified copy
of Darryl Nevius' Westfield Insurance policy confirming the $50,000.00 per-person liability
limits, attached hereto as Exhibit "D".
7. As of the time of the July 12. 2005 accident, Darryl Nevius was not insured by
another policy of insurance that would afford coverage for the claims arising out of the accident.
See, Affidavit of No Additional Insurance executed by Darryl Nevius, attached hereto as Exhibit
"E".
8. As of the time of the July 12, 2005 accident, the decedent, Eric Bishop, was
insured by a Nationwide Mutual Insurance Company auto policy that provided for underinsured
motorist's benefits in the maximum amount of One Hundred Thousand ($100,000.00) Dollars
per-person per occurrence. See, certified copy of Eric Bishop's Nationwide policy attached
hereto as Exhibit "F".
9. Nationwide Mutual Insurance Company has agreed to tender its One Hundred
Thousand ($100,000.00) Dollar policy limits in satisfaction of the Estate's underinsured
motorist's claim arising out of the July 12, 2005 accident.
10. In view ofthe nature of the claim and the tender of all available policy limits,
Your Petitioner considers the offer to be a fair,just and equitable settlement and to be in the best
interest ofthe Estate and the persons entitled by law to recover damages for the death of the
decedent.
11. Eric Bishop died intestate.
2
.
.
12. Eric Bishop was divorced as of the date of his death.
13. Left to survive Eric Bishop as his heirs at law are:
Name
Relationship
Son
Age
Collin Bishop
7816 Wertzville Road
Carlisle, P A 171 03
4 (DOB: 06/18/01)
Tessa Bishop
7816 Wertzville Road
Carlisle, P A 17103
Daughter
8 (DOB: 08/08/97)
14. Your Petitioner retained the firm Navitsky, Olson & Wisneski LLP to prosecute
this action, and entered into a Contingent Fee Agreement with said attorneys for their
professional services, plus expenses. A copy of the Power of Attorney and Fee Agreement is
attached hereto as Exhibit "G".
15. The Power of Attorney and Fee Agreement provides for an attorney's fee of thirty
(30%) percent. However, given the tragic nature of this accident and the limited funds available
to the decedent's beneficiaries, Plaintiffs counsel has offered to reduce his contingency fee to
ten (10%) percent of the amount recovered.
16. Navitsky Olson & Wisneski LLP, on behalf of The Estate of Eric Bishop, has
incurred expenses for investigation, medical records and miscellaneous items totaling Five
Hundred Seventy-Three Dollars and Three ($573.03) Cents. An itemization ofthe expenses is
attached hereto as Exhibit "H".
17. No liens have been asserted in this matter.
18. By reason of the death of the decedent, Eric Bishop, two causes of action arose
against Darryl Nevius: one under the Wrongful Death Act for the benefit of those relatives of
3
the decedent entitled by law to recover damages for his wrongful death, and one under the
Survival Act for the benefit of his Estate to recover damages for his death.
19. By letter dated March 28, 2006, a copy of which is attached hereto as Exhibit "I",
the Commonwealth of Pennsylvania Department of Revenue has agreed to allocate One Hundred
(100%) percent of the settlement proceeds to the Wrongful Death action.
20. Your Petitioner believes that, in accordance with the terms of the Power of
Attorney and Fee Agreement, a fair, just and equitable distribution of all settlement proceeds
would be as follows:
a)
The Estate of Eric Bishop
Wrongful Death allocation (100% of settlement
proceeds)
$134,426.97
Survival Action allocation (0%) of settlement
proceeds)
$ -0-
b)
Navitsky, Olson & Wisneski LLP legal fees
(10% of settlement proceeds)
$ 15,000.00
c)
Navitsky, Olson & Wisneski LLP
reimbursement of expenses
$
573.03
TOTAL
$150,000.00
21. Pursuant to Pennsylvania's Intestacy Law, the One Hundred Thirty-Four
Thousand, Four Hundred Twenty-Six Dollars and Ninety-Seven ($134,426.97) Cents in
Wrongful Death proceeds shall be equally divided between the decedent's issue, Collin Bishop
and Tessa Bishop.
4
.
.
22. Pursuant to Pa. R.C.P. 92206(b)(1), Petitioner, Robert 1. Miller, and Amy Bishop,
who is the mother and guardian of both Collin Bishop and Tessa Bishop, desire that the net
settlement proceeds of Sixty-Seven Thousand Two Hundred Thirteen Dollars and Forty-Eight
($67,213.48) Cents due to Collin Bishop and the net settlement proceeds of Sixty-Seven
Thousand Two Hundred Thirteen Dollars and Forty-Nine ($67,213.49) Cents due to Tessa
Bishop, be placed in structured settlements with Prudential Insurance Company of America that
will provide for guaranteed payouts as follows:
Date
Payment
Collin Bishop (DOB: 06/18/01)
06/18/2019 (age 18)
06/18/2022 (age 21)
06/18/2026 (age 25)
06/18/203J (age 30)
$38,650.65
$40,000.00
$45,000.00
$48,000.00
$ 171,650.65 Total
Tessa Bishop (DOB: 08/18/97)
08/08/2015 (age 18)
08/08/2018 (age 21)
08/08/2022 (age 25)
08/08/2027 (age 30)
$30,000.00
$31,372.17
$38,000.00
$40,000.00
$139,372.17 Total
See, Affidavit of Amy Bishop requesting that the settlement proceeds be placed in the structured
settlements, attached hereto as Exhibit "J", and, see, Prudential Insurance Company's Structured
Settlement Proposal, which includes the payout scheduled and the cost of the structure, attached
hereto as Exhibit "K".
23. Prudential Insurance Company of America is rated by A. M. Best as A+
(superior). See, Prudential Insurance Company rating attached hereto as Exhibit "L".
5
WHEREFORE, Your Petitioner prays that your Honorable Court enter an Order
approving said compromise settlement, directing distribution of proceeds in accordance with the
terms of this Petition and authorizing the Petitioner to sign a Release and to mark the above-
captioned action settled and discontinued.
Respectfully submitted,
l)l~,l~
,
/'
&/L ;JzL
Robert L. Miller, Petitioner
Navitsky, Olson & Wisneski LLP
2040 Linglestown Road, Suite 303
Harrisburg, P A 171110
Counsel for Petitioner
Date: '{- 10-06
6
---
m
><
:t
iii
:::::j
:l>
e:,c hi hit it
STATE OF PENNSYlVANIA
COUNTY OF CUMBERLAND
es ta te of ERIC A BISHOP
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
Register for the Probate of wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 8th day of September, Two Thousand and Five
Letters of ADMINlSTRA T/ON
in common form were granted by the Register of
said County, on the
, late of NORTH MIDDLETON TOWNSHIP
(First Middle, Last)
in said county, deceased, to ROBERT L MILLER
(First, Middle. Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 8th day of September
Two Thousand and Five.
File No. 2005-00805
FA File No. 27-05-0805
Date of Death 7/72/2005
S.S. # 207-68-6515
JiJ 1 n~ 0 ~OvL-(Le1 ( J:b()/lb~
Register Of Wills 0
~()"
~.
Clv~
Deputy
-
m
~
to
~
lJl
G" )( hl~;.t :IS
rag\:: 1 VI 0
.J
1 lnlll 1111 IUI/IIIlII'
WOO26860
c;rash N...mbtr
-,
COiIIIfIl'Oil,'WI!ALTH OF PE7<!NSY"YAI'IIA
PO!.lC1 (!lASlI ilfPORT1NG roRM
Ca5t! ODsed ~"'. c..w,
DY".-No ,-Ve, 0010
Lb
AASOO 1
I [~,,,",,-- ..._-=,=... -"-ilp+:ll;-j
Ii ISllver Spnng Township 1121/212 I 07 -[:!L}r2005 I
IJ ~.... Tlmo ""~ A_ n... _ ~- ~......... I
J _f 2220 II 2223 IISG~ JAMES R. SADLER I 1 2404 --.J
I -- _.. iP""'"'('" l",,"PD-VYYI'j
,"rc';;;;'-<';"~H;..;'- .-- ......0..1'" ~.~......... '=~.-!::;:;LL=,,;.:;-::;.J-.
i' ~ (Cumberland 11212 IISIIver Spring Township I 0.... 0 Thu I.
~ :".--;-.- 0 Mon 0 Fn
2 CT.uh ~. "..tM-DQo.vY'fY) 0'.." nr..lmItJ No" Uni'Cs....... 1t1iu. I(ila..r- --.N,. AD . f 0 501'
~llo7 1-\12 \-r2oo5 112220 1rr=J\2 111 111 ~O~:dOU;.t
1~=#-~~;;~.":. :c::o.~,=:~~&~:;:..I.~::: 0 i5".~;:~~~. ~~'i;~'~'
, . ....".,"'" 0'1"--_ 01'l''''C-- Oon'::~ OC-. O~"" .-
~ ........... R~AlClAbM "...-. .:~iIJV. ~'"".. : "~~~ .
. _, .... :s.:n--= - ..'. _,.. ,. ~,~"<,,,,~<';"'. ....._.......:...;,... _--.:::.-=-=,:~
Reule NYftJIlet ~ (OP~l) lQyl'1 ~rM!I $peed UIIIIt 0 ~i)rTjl f Nouc. trtiMftb8r lit "'ttlicatH) 1
fJ 10011 II I ~ GLJ '~.l"''' ..16480 I J
1:- StNM NlUM S~ tNtlftg I 0 fMt ro, "."". 1Ojj. (RIl,!I<e' 0"'11 VSl:
. I I I ~ 0 .~'t:j.\ ~1<<l'-~"f1dm~lt.1,"",
~ I CARLISLE ~ ~ O~" ","~~:-~~~~i"
i" ~~ 0 ~~.t't 0 ~=nl ,0 r:J'I~ . ~tiltl! 0 ~':~ 0 ~!tr~~ 0 =e 0_ ~~
- .~._,~._ _.- \....,.-.:Il._~,~....,.. ~ - __ _.-:,'~~O..~""''I'__~''7:'''P;.-~.
I ".... Humber ~ -i00t101\lll) f,." LMes $"" L_h 0
J o~ I II I D D 'i~ 0;::
f '5'1:fIMt IbfIUl stl"Ot\ tndint 0 h}\
· 11".0"'''''
.. . L--l 0 O~n(l""'n
f ! ~ 0 lrt~n"'llt 0 1~t 0 l\JflWo.t~ 0 ~"lr 0 (QUI'I()t 0 loc.t1IlDiKf C> f'!i.!.l1e
S t,,* lUlngii:eJ (bstMMU $0\,1' Hi9'l'.N.IY P.(\Ie .0' Sveet Road
1~.1 MuM Or M;s.Pot1 Or SegJMflt Marbr
~ " lb,1'lO '" I II I 0 I I 1! C) North Di~~n(t kenl Cr~
III ! Th' 0"", i! , . 00 \ .. "oo.., _d.,,,,. 1
, I '! Or ....1"IedIft. St,... "'IM 5t: t'~ 0 OJ 'For rJ.Jh ~twn"
S 'I III filS! l.a.ndrrwrft1arrd
, L--I 0 W.., tondmorl< 2)
:::,~~~~~~~~7~~I~=~~d
r~l~ -- -- (1I.M.w ~;":.-~;; ;;.;'~~; LInA ra-~ 0 N~ -""0' ~.ast. . No;;:';~~;-6 '~i
,)&: 0.:"'-"""'. O........,~ . Fun, .2.:::,-..1- 0 Sou," O~:,:, 0.'''''',"''''"'' ;;;,.!.w) II
.f. l[1I.,L..t( v_. ~D' ~ ~
l.li.:::~.~ 1"1I:1'1000',,,, O__L ~ O~3I)~." D~v-Ef.lv.ir., OI.lt1l~ .}.~h.~ D6.-J;,~ O)<:tI\>l.\tI'~ O!)f\lt~.(7l,Y!1 t
- ~~-==--- .==--- -~ ~ .. ..-'<"""'.-;,-.-..- -,-.'''''-=.=...''. .,.....,,:;,...,.-.,. ,..,".;",',... ,.,.",-"""-,,~---,,":-=,,,.,=-.=.,..~
._~
j
~
o O:;hCl":j'
Vtok,.<,,"'n
._n._ 1
Il
.
I'OftN.......I\Mll)
l'IlNNDOT COPY
http://www.dot6.state.pa.us/crash.mflPrint?OpenAgent&a=2005156280t= 1 u=tmmullen24... 8/3012005
R/7.rI IORO'ON <~Ilnrl rll~QNMnI ~rlQ ~<^lIQ WrlIO: I onn7 'or.2nv
rage /. 01 a
-.J
mlltlUlllll1
OHh Nvmber I
C~OJ;OIiI~g.l..m; ~ ~l!lI1II'IS;1I'~V"';\\I'"
IIOLlCE O'Jl5W ~!POi\'f&l'<<> ~OflIVj
I ELl
w0026860
AA 500 2 t~u~Oo>.'
, , !l2!,;r...'."'~~~~hr~';"i(\"O.:Li~ ~~ V;'hi{I, 0 ~~lty P,trhd a Ittg.lUy PRI'.<~ 0 NQII' Mp:Otl1lfd ea.mn..rci~' V.4vc,.g
; S Unit .-." a. O. ~F 0 Vf'S . No
., ~ _ 0 Ped~riMl 0 ~~~ CH:' ",,,,,'es, 0 Mb-.. f~ 0 1',..,n 0 Pl-wlnlorn'llfl':'.id!: I
4 ,,'WlI#;d\air. II'\(; ft'l!'\.'OJ): (riSh (If nS, <'.om1:lI".'arm C)
_J!!'~~"_:'~.".-~~i~M".onJiJt("lnWMrId,~.,.!(..r:onwl~.~mM.S~c.l1on2" . ----=--_ . _ ~
-1 Uftlt P<<> First.... M_ OaM> of 1I111h("'fM-OD-"YY~~j l~
1 @O I DARRYL I If] [EL] ~ '1987 I
I
;I Dtlfff; un N.... T".Phtl~ Nu"""
o I NEVIUS II
""'M" J ON I Stale ~-
jj 1101 SILVER SPRINGS ROAD MECHANICSBURG PA
Qr;..er liu.. N\tmbl'r
. 127860469
5
'I
'.' Alcohot r.d romr
; ~ 0 r~tNotGr~
.lO _.."'"
'I _~_..,~
. [Q].~
717 -691-4129
""
1117050
1
I
Stat. O~,
i~\c
.-
AI~S~
.NO O"~l~
o Al(ohel 0 A.ktlhol.,nli LA9'J
-.-
_..._"'o>k.>I"""""""
_ .t.pp;uMlly 0 '~!Yl ()t.Ig 0 ~ati,.,...
Ni'lrm.ill USoI: ""~.
o ~:"n 0 5-<::" 0 ~'t
---~_.~~--,---~--.,
o ~1"kf'Own
a Medil:8t'ion
DMP:'d(:.itJOO
OI)n~",(ft\lI't
Olir-Nth
DUr~
00,,,,,
O~~nlf
PriMaIY vehJde CodP VW'allon
IRECKLESS DRIVING
ChifVtd?
l_'t'l"\D,)I(l
o T~~ Rt:iusfC'
OTe~tG~.
("OlltarnIMt~lllHlLlI,
D~.~kl:~
DdvrN ~.
l.,.m~~ Op('ra';l'd
\1M"
20=.N0 Dli"lf'f
:J,,~r~oj$(~
.Q.,otUl~"dllun -L
9=.\.lIlkr('r.A'n
~
Owrt<trO'tl~(J();.Nj)l~liClb:e
~ OI...Pl'N"'>>V~'lIdtOwned'
~ lta5edOtOri..,
ChP,,,,,..tr \letlide Ho~
~Dt~;se<ltlyt)ri',oe,
Ol.."ll'l'\lfld"i-"'(Ie-
Qf.=SqM ,101<. ye.r.ic:lr
OS-l'tNNOOl V~r<;1e
060:01)'0< >\:11(' G<.w Vl?n
07-M1.1NtJINt p(>lic.t \'t~.
o&..Q1~ ',~\p.
Gc:r-~l'1"':"It'...\\~i(l,
fJ!}.F<<terJl GoY Yen
9"""""
99-0U...It"o......
~ Loft ..... or .iu-;~~'7;r~<<;n:j;;;;~.~s,criof;) -.. ~
II NEViUS
V...tcJ.Mat.
II Plymouth
..,...1d4 Uodt&
ILR4
TtNlIH8i'
I MILLER & SAM'S
='-0 11~;.t: . - ..
Add.... I Oh-, ""'... , ZIp
101 SILVER SPRINGS RD MECHANICSBURG PA 170507
I
-M8t.c.od.
I~
(..."""'1\
I
I
I
--
h"Vear TilgSt
ID
\/IN
I 4P3CT 44U6NE024272
Lioem. ..~..
I FVR0932
Modtt 'i..,
111992
fl... -'t bt. s,..a: Vd~~ TWoWod
I ~ 1080 I .'" 0".
Polley NQ
II APV1617489
_urflrlCe (All'lpitIIJ
o ~,"IWESTFIELD INS.
~wr.1'K@'
i -."" 0''''
, !
..
I: ~QIIl')O' rsa .Ve"""I'Nlbo"
l~W# L:.J
~ Color v~.. ~ OS=l.1ln;# Tn:.c:t
riYiI O~"Yr.f;Q\Y @C] 01.AlJ~ornolJilt 05.>o'sv....
~ or.~~ 01 lJZ.MOl;ort'tf:!'f C1"_V~1'l
08:=.6old 03..aus. \ D.5"ow.,.,~ltI
Ql;::Bl~ ~nM'f'l 04=SmatTr\IIX 11_Fim1EQUip
Ol=~" lQ-Or~ Of "OJ". CompIe-re Fonn 12-<;(lno,"YV(\"0" tq:.io
O'.\NI'IJ1.f: 11=PwpIt "t Srttion~) 13=AT\.'
04.:-G1"t'If'I 12~~1 m"2o-"OT"2r~ C&mpt.u# 18,"Ott'rtfl'n>e~VI.""
O~.I!IIf(t 99o<'~IIO'N" fGrtff M. ~ UJ 19=1JlU T')'p@ SPK V~h
t IrUtAIImIlKt hint 0...... I1J4icator
j' n ~1 OO=Nolt-,-oI1IUOf'l 1.:Ur-dera"'lige- rj11).1>i~ 2"flJl't':10l':'",1
III L..:.:....-J 01,12=CkricP.:lItxs lS:::rT(7o'LlI!dUnIl i.:J lcM11'10" '''C~r~
I 1:).1;)11 9j-IJnknaYm IhUnlo;noo...-n
~-..r~~...."::&,\:...;-~-~---' _...,.~..._.....
TJ::'~""Of@]
- T~ilinlJ
Ul'1'O:
~ 1~T'~~ng ...,s. '''tf\ 4.PA~~f HMl-e l=>~"mi-Tf;Jder Tag No
lIiiIt 0 ~",town"Q 11l,.1(): ~..c.,.,~ t1.othl:'l I
- 3::iT~"nq Uli1it, TrOJiRt 6=fu1l Tlatl4!1 9~.nq.Nr'l
-..----.-.,---.....--.- .....-
@I:J
II
..\.lm.nt ~
....
O...r.y
--
M~qcJ.. BK)'C~.
T,jt.~
Jl-orn"'~~
l~~&eUC>>i
2)~OiRic;I"..
;z.t.Tr......
25='frtllley
98.0\1'\('1
99=VnU:Cl'NI'I
IDfcNI 01.......
~
12~o....~.a1
P.a~".t'l'\Ot'f
Carl<<
l?dillll;
2.'..lt.cKl,r'4i1er
;!:):.r....:n lr....
2).~1'r..ilrw
;'.:lv'lodiii'!dV~
og",'JllknC)Wl'l
~No1 ,""p,MabIF
Ctcfrn! \/O!h
0, =Ambul(lrtt
o)._".,l.t,.
O'i.otI'lf'I ~/TlfJ9tllC'f
vllhU;1o:!
1 1dl'up;1 "'~/'lUIOrt
~
ml....j:';'II:1
l.:J 2-lJp~,nl
~d A1UarvnMf
ITl I:'''..,'' i
L....J ZwoClll'W't(.!
~l,!n~na...t'1
=....,...---=---"""
).,.~nhii!.
r.dlotulm 01 Hill
'5.ToPoi l.n\
r.J..un~'"
___...._._._ ===-=""'=:4'"".,~."..,
lC()Il"."',~Ila.\>>1
PENNDOT COPY
http:/ fwww.dQt6.state.pa.us/crash.nsfIPrint?OpenAgent&a=2005156280t= 1 u=tmmullen24...
U~.~ IC~Q.O~ ,~Il~~ AIU~~IMnI ~A~ U,^ll~ ~~ln.1
8/30/2005
cnnl .n~'l~\i
r a~t' J U.I. 0
..J
~llIIlmlllll
Crash Mumber --,
"lllI<I.~""QW'ljl!'lUd_~ 0:< ~I!OOM$\'t\!'AiW.
l?ClICIf 0....$t4 R~POlr.il't" fOflll/i
,....:
AA 500 2 /""'''''''''' I [iJ
"ijOOi:. ~--~q::::d~';;'~::';'i::~:':~ ::::: ~ ;::' ,,~'" ~ ::om:::: i::.;~;;::"-II
;) ,., ~eHc~lT. I!'tc "'P\'iO&..i Ct..~'h (I'f Yti. CotI1pletl! foun 0
. (If .,~~trliUl .~ .Pedt:J"~r1 ,,!rr ~..i'C5._,it W~h,it-.__.,~c', ('om~r" Fm17l 41, S4'eJlDtlJ6)'L "-,-","<"'4.><~~'-=L...I:.-"--"'-~' '- --I
Urdt "40 "m ...... Mil D~~ of 8111tl (',".l.oo-.,.,.'()"!
~ I ERIC I EJ GE::J [3L] 11976 I
"'NI!"'. T".~ ~... '
"';!5' I BISHOP ! ! -,
Acldress J Citv I 'State Zip
..j 1159AMYORIVECARLlSLEPA ![17013 I:
, Odwr lJClt...s.e HumlH-r S~'" C1aj$
124356182 I ~ Ic j
'! ---.. "-~.._.."'lOWIl>oodftIon- I
'I 0 '''' 0 il. (J"'4 0 ~i'JQt'l 0 ,.&.pP41etltly 0 "'.'''' i ="l,>g 0 ~t1;:.,~ 0 Medicft'c<ll
' '''DI~1 lJY- '#
. . A!~.j-o'" 0 .Altol'lut .,lI1">~ Of\;~ 0 U!'lli:~.owl"> 0 Kid9een 0 S-;(iL 0 ~""l'ej;l . l)I'lltl'lOlr......
:. '1-' - --------- ..__,...Jlc'~_.._.,,_._._,,"..________..____
; . AJcoMI F"E'st '~H "'...'" "MJde ~ V~(IOr, CllargrtdJ
o TO<. t Nell GI\'2'"t 0 &re.nl'> 0 Other I
; .. . S'_ 0 u.... 0 Uok"",... 'f NONE I 0.... ."'
'V fp.stGI'/'en ~ .
li _._
J AkfIhGIfll!'Jf.te1Ulu 0 TmRt\l\tO 0 ~~ fIrM4~ l.n/h-~Oper&fed l..OrlVtt"..(',j)~~
fQl. ~ 0 I~' G~..,_ C1l \,'e""lk" 4..liif ~~" ll!"n --1-
~ ~ (Qt'It:wl'14nb(~ ~lJll) U 2::.Nc Ol,\o("t g..vnlcnowl'l
WOO26B60
o""'"~ C)(),,:flol Appllt~
I()1l Cl;O'~.iI...1le 'P.hi~1~ (}...'1'Jt.df
~ l.H6ed by 0"-10'1'1
C~.P7W:i_ Venide NQ-~
OwnE~iS~ by Drk@f
I)J..R~fd VN>i~l"
041a$ttt"'<:ljj" V'ini,ll"
tl$..KNNOO1'VIfi"J(1q
06~~\fIS\.JI('fjo;wVf'''
07::Mullicip.ll A:;IIi,:;. wh
C3~t~'''.'''.'lC;p.ll
G(M,"'I~l;"nt '.1_hlCltr
09~n) Gcu vjh
9s..OIt~1
9'jTUI111noWf1
--. ~. G;iNlocn<< ;,"i'uti""- N;;;;.1i'-~~-~kjp th.i,.~,
I I BISHOP
~aIIl. as i,Ow,*,",," .....m;
pri... 0 II ERIC A
Add,., J City I stat. I Zip
18 MARILYN OR CARLISLE PA 170137013
I
.-.-
I~
(~!'CNfr\iJy)
I
I
I
v~. U.k.
II Plymouth
v.Nc.1, Mod..
I BREEZE
",.
j1P3EJ46C7VN718862
'Lic.enle~
I EBP4071
T6wtJd'ey
I MILLER & SAM'S
tmw..,..
http;//www.dot6.state.pa.us/crash.nsflPrin1?OpenAgem&a=2005156280t= 1 u=1mmullen24... 8/30/2005
Un'rl IC~Q'O\I 1~llnrl rlIU~\IMnl ~rl~ ~1^11~ ~rlQn'l cnn7 'nr!n~
Uftit No hnotl Me 0... GleIm. (M....-DD.yY'rV} ^ B ( I) E G H
~ @i:.J a"" ~-~-11987 1[D0EJEJ~~[2]@][]
I Nlmt 1 Md....' PIII"_ I IMS Tr.,,~
I O~.:,INEVIUS, DARRYL P 101 SILVER SPRINGS ROAD MECHANICSBURG P .v., ONO\
i-unllNo hrtal\PM Oelo1t;.-.o;;;,......h1"b':MM-DD.-rm1 ."'--.. --~-~.e c "'o"'-"""'=>~':"'f- f c~ t
[20 ~"dd;;'I/.QP-~-i1976 IEl0ElEl@O~~!-?..~ I.
O~~.~IBISHOP.ERICA159AMYDRIVECARlISLEPA17013 I DYe; _NO!
DO ~? o11MMir IDDDDD[~JODo'-i
I EMS Trafllpon I
,Dr" 0",
-1
''''';''''''"
pPf'tM rYr4l'-
A 1"Or.\lef
l:.P.ss.er>~
7~l'l'lolI"
8=OtIW1
9"Vnlo1':OWn
- ~~rirvt
D _NOC A'.lI;.~IO(C~1
Ot""OrNtr" All V~"iode.
02"0"1 Sf:0t MIdcJo!: l'\o",t;on
OJ.,Cnt SHt Rig!'!l Sid@
/}4:.:.)e(()l'Jd ~ . left SiI>> 0'
Motorc,dit 'il\1~ngtr
Q5..SQ(ond ~ . M~iI!' ~yUor1
O6orS4teond ~ . A<<Jht Side
07..1hrd ttaw'Oo GreiJ't~-
Left SidE
OB=Third r~ Of c.l'fJf'" .
Mddlt Pv)lliu...
09... Thrd .11.1>\' r:r G~n'~ .
A;ifll~
IO",S1M~.r~()",qfr'l,;(i.(.\lJ
f'.:t)()'~ltrf.fd">4!d
P.wnljler 0' r.~ ArN
12~~A.'1!iI
ia.,;:x Of P?;:up. (t(.)
13ct,..'tll) Ur,il
14.,Ri:(t.r9C>': 'iehide t/lferiof
'&<;Bvs '''!IlI"'ler
""Ottl..
99-UA'<nO'"""
l<!!
B f =~l!""le
M=Mdle
iJ =Ur$:I\OW""'
~,
C O=rN(l.t~lJrf't'l
l~"'(ltd
Z,M*"lnjury
3=M~
~!"\jur~
....MinQfir......'"
8-1n,jury. UnO:
'''"'''''
9",Ur'o:'~w';.
.,,""
"'" '-"'" ISILVER SPRING AMBULA
-----
,--, -
ff;1lrl'llt- I AddrKS J PhoM-
, Os.mt'iD I
()P@'Atof"
l'age 'I or ~
IIIRmlll~1111
Ct"'lh N\l"'~ I
''''
I l!:J
W0026e60
. ~";'nl(1'" -~'*";;;-'i::~:~ "-,
E OO~ lh!d J )<<:Jt APC4Cjbl(! G o=lrWot; AJlpPablt'
01:Shoulder hit Uwd t=NOt EjoKted
"'''''''' ..., u"" "'0"'" ~I"''''
O~~ AN!. $llOJJfdil!' hll i..'~ joo.pertl'allyl::ject~
O'=CI'..... ~,.,~ty SN' VNd 9-U",kIlO\l',n
O$,.loAvtot<y~~ ...,IrT\ft.JW'j
06=BlC'f(i! 1-ie-1rlIel Used
to..5.l~1y 8ellhed InlpfGPcr1j
1 r =Cn~11 S.i~y ~..: U$~ :-rr.~I'1'(
HfII~..It't~I\I~;".pl.l)p'l!rly
9Chliti~"' U'ltd. T)''O~ \Jfo~no....1'\
9't=OOnov.Tl
I
I
!
,
H ~~d/l"''''''''~'
1=lhtoo..,~,_>dl! 000' ~~~
z= Throu9" Side W",doollo'
l=lhra:Jgh~'ltl
;l..-rhrO"QtI'j()((l(A\J
1Lft:&. "1lf1l'r1l'lWf'11 n...tl ~.nl"~'Jgh 3t~k DQQI' T~;~\It Op~.ng
F oo.l~1lo"'<< U\l!d I Nc.t !....,lk~4! ~ rr.rOI.l~ ~tl" OllfR(IoQ tSunrooll
F"'" (Qn'olenlclt> ro~ O~l
Oh. !'Or11..\fI tl.I9 ':;.l)(~ Ifl)( ~ SNt) 1="hfOU..... 1l.OO' ~~ ((,)1'W@r11tJ,1p
02-!lKk tw ililq ~IO'~d fJo/ r-~ 5N\1 T~ ~;
03...Qt,~ tyOt All fl..y ~'t'C- ^ Un
04=Mul~;pt! All 9ag~ lnPO'JI'd ,,= Itn~'" ~
05=MctOf'CJ'd,-lye flIOI-Kl,O"l
a6=/tkydlst. wo,t.n9 E:t::I().~"ll:f'INi;'-d~ UtDJ:-.d '
1o-.AIt 8189 H~ Otorll)jr('CI, '5rM,,-" Qr1 ;f.'Nt.l~piiCM>!t
i lo.M $fil N..,*lt DrDlcr)ltd. SVJi>t:h 0" ! ,Nc!1 fxlritmed
l;'rA'" ~ .N<:>t, [)eplo,..-d" J.=[:.rt:"ated By M<<ho1l")lc;,I MHos
'l~ltO::I~~~"fir:lr 'To (ra~ ~:f B)' ~n . M~[MnIt. '~n~
19=u~tfAira~0f',pk)./\!'I1 ~r')I(":),,,,1'I .\
99~Vn~~ '
,
,._"...,,,"...,,,,,~.,,,,......., _ ,0. ..,..=....-.-..--,f'OC:lt:.,<*:.~~
I-u' ,.dlOy. I PINNACLE HEALTH HOSPITAL HARRISB P
.-.'."-.-. _...':',.;'c.....~------;
~...,"o'.'~__...
Uftlt No hf'Jon No
DO
De-! ) OttalOf.~1MM:(,~yVYl
O' D-D-r
- A, .8 C~. '0' ~I ~ . "''G' - 'k'. r -'r
IDDDDDDODO
NuI./~u./~.
D~~.:r I
1 fMi b,mpon
Ov".. DNo
D[~:ro'EJD~T I[J[JDDDDDOO-
NMM'~~n'~o~ [~S~~
: o~:..1 ] OYe\ Or~(l
II DO i~~-'crc~rL_~_JDOODDDDoo~""
Milme , Addres f II'h<ane fillS T~JpQ"
O~;':rl 1 Oy~ Ofj~
- ....---" --..,... ..&._:r::.,..'1t ...--._. ,', .,...--......., ....-=.-:;~'"'"'-_.
~1III.~(I~
'ElIINDOT COP'
http://www.dQt6.state.pa.us/crash.nsflPrint~OpenAgent&a~200 5156280t= 1 u=tmmullen24... 8/30/2005
k/r..,.l l('~liG'Okl ::l"l11il,..l .lIUC'kl1Aill C'I,.l~ UHllC' ~..IQn' I cnn7 .nr.lilnl-l
ragt: J U1 "
~
1110111I1116
-,
CO!li~ROlolWEALTIi OF PEII!I\!SYL\l.<lN..I\,
POUCE CRASM ~POR7ING FQR(1Il
AA 500 4
CtMh ltumbe,
....
I [LJ
WOO26860
rlr~.;--=:~.-' [i] o.Ncm.(;olt&i3n 2~;6n >='~'~".""~;:~~,'" -~~. -- - ~ ;ril ~~~ :
hil~- . ,._....,:.~"!!~~ '.~~"":'"I ",,,,.':~""I~,->'l
J1 i,I~JtI'Qftf(l;~crw..tr r:jI l,,().,TrawlLerwa 3",J.le:t8n ~-ouca."r.iItcNey '~DflIlflarnpl",,'MCtOnI
:; ~ h L:.J 2-~f hAQ~ 8~1n PIIltit'lg Lane ~/JI'lJu"oa'al#l
'1! ~r=~-~- ~.-' [] ~~ 'j'=B;~,;~'-~ -==;,"::"''i$~-' - .---~"~" !i
']~ .2. '1-"" ""',u_.__........._.. ,....- _rl!'!!~~=n...~;.Of'~-;-:--"..=..~=~~~~etl_ -=- _- _-____=_ = - - _u_ _,.__,1
tlE?-=-io~~i~""~~.'"-~-~- -:'":~:~j
:-r~--; r~-~iD":'I~~~b" ' , "~~"l?~~=~rl= ~t$~~r'" '":1
......., D 0 iJ)...:IWl ll'\d 3 l3t;~I.' BOd",." 0. ""',m"" 1\
~Ol' 0 I C14'~IU,," 14'"',"_End 1'1'
I ~ ' 0"j.,J.f;\ VnitS }5.~1{ !!fld9l' RiJiI
06=.KiI Olhr.!:l T'atf~ ll"" ~rt .8~f:let 0< Q~.Y,i'lt
~~ 7:,t J r-l 0 0 I ~::::: =, A~ITllil )7:~~~ ~"It~m'
~t'llti.l( L-.J P9..c;OII\rl)f'I'Mlt1O\P\(lI,"i{'ll'l ]1l;:HIIR~~,YI'
0<<1<' CJ ~Otlj(ct n.tt>1 iltb.'Jciw~y f,~f,:""f:<<,
lit . 0 0 I 1 t.~A,l(); ~ Ul'Ill 1 1l'J-.~;1 M~ ,9T;Jl'
1,. ll-:'.it~!JoIJ"'i~i .,IGH~t1ratl.r.kI~
"I"r 'Mlr.K~8Y\.ltlit3 42....N-c;ntw~nk
Ii: I '4=StllJa- BY ~i! -4 43,Hi\ TftYlpol&r"/ C~r>.Ictlc.n
I .l! l HiITII hM L!. Mcue' Utllcy ,.1,Nunbcr lSoQlfUd: ~ U.,i, ~ 81fFlt'l
i"'.j1l 0 . [ 160::Slr,o<l By O~ !raN,( 1Yl1~ 118:1111 ~ ~llCt'd C't\@('!
I~I!, I Unit No ~ 11....MJ\ 1!I:t Or ?\"\.I~ !lg,.l'il'l i.It'l~I'Kl"''"' f1~~ o..~lro,.,
J:z.,..H.\ ~l1Ibarl~~>' ~"Cyer:ut~(ltl 0\0
li~!:O:, r;;;;--,.02. 211 00 I B~ll'\itlh'~I(' ~'.So\ruf.ABv1llr(t(>ifl0(f.eninq
_ E--J L-.J, ]4.:.Yit lr~lfic 5-~" r:l:lMI
25=t'fit Gvald ,,_t 'kGF\l' ~ :)1 Otl'~
I' ~"P~f. 0 0 I I ,...,i.{ ~rali\~l End p~. '.r::'lffT,~llntje;
( In 0 j17l1:1'lit (;.lIt! ~3=J~(~nifi!
~NI ~~rt CClnc"tttOt 54:flri' If: 'hil'>>d,
\ 0n1v II 0 II . tongitudinaI8,JJ1i!f' 5a;:Olhlr-~:F'-Colit(;!l
4 L-.J 0 , ===:l119=t1i\ Gt1,h 9'3=U'*l'lCWf1 tY!tnfl.)l h"H\[
,,~ Ft" 1~"1"'1 i;'-i . I~~"l~'~;~~;;:--' -:;:~E~:~~ ----,
II . ~ ~ 1 D.2=OrMftg i,..W.;I Hand ~lI!ftJ f'1(\!'P. Sidr 01 t:to.ld
-!\. _ ',l,_.......II~C'jv.___~...~P"9'" _~__ l)l-Or~9lk>ntJt'ldf'l.tlr:'ttf'hOt)t !9"hliIljr,;1(ff.~
11"0;- ~:::;--",:~':"--<(OO 1,0 "-0 5*:;;~~;~1 ~,!;i1~ -1 ~
~ SI di tr ~A O?~oceedI1'4VNO C1...c-'ft'.Ir:1L\ p..,.t,,~"'\.I~''hIJ1 1,
QO.N~ 11"~hpt)tf_1' itOilu ((It! I,itlF\~ Ikl"JI'l"p, ClWar.(e-Al~f Stop 22=Ov!f!\lnjef Ii
01.Wtrtdt (bl'difitns ll=Sut$l.;II'\:1! On It.m''l~ OI3"R\JMl",~ 'SI~. $iQfl Cc.crp1satlM ,M (Ul'\~ }:
Ol""'i",~r. V.1U~~~ C.,..,dtnof'l'l. 1)_F<oll'odes OSI~lfVlil'lQ 11M 119'-1 lhSp{lQdnQ
I OJ=OIherw.,'t!l!< (~l'jit'ON ,.",8tetc.ll\ 0.' ('M~<<l P~.11 lCl=hikllli! '1-0 Itell):;.rld To :i:~n.; 100) "~: fo.r ':'O"(UO~~ 'J
I. 04:ae,.-1n ~dway lS_TCD omt:\t{~ . OVtl'l' Ir.1'ht (Om,:QI ~~ J!:..Jarl",. ~~ Ml!lnIJllf'l?o~ ~M ~
O~~t)b~.C,,~.,/ l&=!.ofI1t\>)ldilrOlsro..!~Orop()'f 11::>.'1~ln9 'l!)l:'lt " f''''' ,......(-, ~
I C/.6..(nl'ltrArth:Tl"I"~W<I~ ll=Octl!l~yril(,It.l1 l~.Sud"drrll~Io"'~' tuPMg '0" 1fI" Olng ...,(t'iJ'ti. '\i)l.l
{ 01...(.!-- .,. ~- , ~ , " ,,,-... S 0 ~ "",' 27..Qriwr ltlI.:i'!lfI'<<'.(l!olJ
11'C...r <6-,-","",' """'ONt.l'll'll"" a(1(JJ --.~.. toe, I'll)"" 2e~I~1'O\iv._'5:)l'l.i.....:rdEOwo
~'r:c 08=Wor1.: lone Ite~d ~.LWIfQYrll'l M",c..art~ Pu'I'9 ~ l.~ 92..A~le'd I)y ,2i,',"(iI! (Cl'ld'llO'i
l.J (I~. a
II ,.,......~hiJurnM (l..W....,. 1~",.W;nO"'Nof"~;~~ZOI'll,' ')6~tntrtmCl'ODP' flvl"9""'--UOns
,',' OO~~ Of.::.E';'iN51 J 3.crll.,.r '5n'!irJl;fCml,Trf U;"DroMn? n..e wKIIg \\'a~ 01" 99o.l.;i..'1k,1"1"Yf'l
. C1h:lirK Q7=Headight5 U*ctr, ():lO~. ~m. E~c I-W..y')\f\:'tI
O~"rM~ DfJo:="Sq,iIIuglt.l!, r')=":JilPl-jitd> @IJ @::J [3D ~ D
(~ Ok')~M11l0, SyfM~ O'ikOt\lIf l'T-lS ti:i:....~ g:, 01 1:23 2 24 ) 98 .
';:: (l4.:.S\J:.perl~ lo.-tom P=.Airt;.oM;s
i O~Tru 11=Mirrm ;;:I;~~~ ~ r;;::::::--, r--1 CJ r--l
s ~ilEI ~J,D 20"~~~"~ ~~1~2L-Jl 6L-J
~ roo! II ~~lr~W.11 hield .....::;;;-..;;.;;lonm (l.)=won.:"9
r:. ~ 1 ~2 ~~_~,:.,~_,=~...~ ~:E~~~~A' ~~~~d~~"3vn(~ II,
1ndk~"iIM"'cffN untt!'to Feaot Cod. 1'1 lJl=v..alll,i"O, I\u~.,if'l;). ~ ()7=;trd~
, 0;. ~ It._ """ .nl\;"""''''''' "" r;;:;--,. r;:::;;l Or ,.,a.'r'i"'9 98",O~ff 'I
a _~..,~_ ~ ~ 'j ~:U"'.n(r"'"
_~~o=~"_~=_~_~~f.~;~~;~~__L"::~~~~___I ~ v~,..@I] .~~ _I i
~~M..."!I!('I~ PF.tiNU01' CO~
I'
"
:i
11
'I
I
I
I
I
!
http://www.dot6.Slate.pa.us/crash.nsf/Print?OpenAgent&a~20051562801= 1 u=1mmullen24. 8/30/2005
~/Q.,4 jC~{l'O"1 )'111(\,,.1 ,.l!UC'~IAi.(\,1 C\,.IC' UJt-.11C' i,I.J,.I~n'! cnn7 ,nr.9nl'l'
r4gc: OVl 0
-.J
IIUllllllllml1 ,-0 ~_ ,
eOMMONWtALTH Of PENNSVLVANIA
POUef ClIASIl RfPOflTING fQRM
''''
IT:]
WO026S60
AA 500 5 I f\;tu:lkC~""
.
a
.,,;
Ph...
"
WI~tHIl"M
1 SEE INVESTIGATOR
_.
~
Nan.atWe ilnd ~ddldonal w~ A<<lden' 1"~iI~ Notif~nj$S~l 0 ,'.rtr ~.
The crash occurred on the Carlisle Pike (SROO11) just west of the intersection of Sample
Bridge Rd The roadway at Ihis location IS live lanes. 2 lanes north bound. 2 south bound
lanes and a center lelllum lane
i
~
.
z
1
" i
t
Units 1 and Z were both travelling south bound in Ihe righllane of travel. Unil # 1 which was
travelling al a very high rale of speed approached Ihe slower moving Unit # 2 from 1M rear.
Unit # 1 struck Unit /I 2 in the rear. This causing unit 2 \0 skid oul of control, striking a
concrete curb and flipping 0'110 ils roof The unit ronlinued 10 slide on ils roof until coming
to an uncontrolled resl on the roadway.
After impact Unit #1 sk,dded out of control coming to a uncontrolled rest on the roadway
Witnesses reponed that the Unit #1 was travelling In ellcess of 100 MPH prior to Ih e crash
SEE: PolIce department irwestigalory report.
FOPl.U._XOflVlrlJ
PENNDOT COPV'
hnp:/ /www.dot6.state.pa.us/crash.nsflPrint?OpenAgent&a=2005156280t= 1 u=tmmuJlen24... 8/30/2005
~/!..l IrCQ'lHI ]'\llru Jlu(,~lijnl C'\JC' \.l]^1!(' 1AI.l~n'l r.n117 ,nr.9n'r1
-.J
~~Ii.')Ql;l.~f4.vn(i o~ 1?Il,",\ll~1!M'Il.I1I[;p,
~C2 illUlll:<I'_lilViml 1i'@Illr.!i
AA 500 F ,...........,..,
....
I [L]
....,,~1'vJJII
~,'._"-"~'"
r ,. Jurhdlrtim'l 0 Mlli'tary 0 o.t.- Jlecn"! $'ttd
. IIoSo<cl" O-'~'" 0""'"
Juradictian
O KltiOftoll ",Il a (DlkgtNntv~ 0 Unknown
.....US
~ ~ - -,.....~-- - ... ..-.
~ tMlpl'''' UM: ~on fw Hdll.Il'It lrwatwed ih a ~ uMh. Do not ........' the Infoll'l'oitiM in 1tte t~.bcM Oft ~M petgeS.
_ .",'~_ _______ ;P'.'l;' -_~._'
UtjtlCo h/ndaIlf....cf""'r .
~ 0........".... all 11 of!
01~020
OO'OJO
DO '0
(17 OSO
o 0
"""....
@Q
-~ 0.'
~1!!r ConopllodW100
. 0 lKt.ktlOnf ~
........Ilc<;_ Conoplied_
"'" - 0 .........,.
DtWBEJt.Io" ~.c O~INd. aNot.~v~j.
!l!!!ii!I!Illl . ......... W11l> 0....
O~-Noo QUtlll.no,*,"
. MaI'1il! Reqf.A~d ~ ~Uolt'lCl:
o _ln4.
~ Unll\QW1l
0""'.-....... oU01l< K(Ill. 0'
V1hi~ a.u <Dt ~ulte4
o No".Ikf~ ONol.llPMiWflvaoi.a
to, CIID' om.
o tkrt'UceMed .=Lb,.,.W OuntnO\lJfl
"
0",""""
--"p
o Brid:qrlllocll
o !lo1V, "'-' ..
"...
~
Gr.a r..,. ."..
. ....
0_
DUrn-
Dr-. ,.......... . RID fD floW IldutbJ
CI . "~ T~ GtwM OJ. .. .~Mtt"",n6
~ ."0 [)lug a.poIWd ". "'"
:I: _ M..!'jiUIN . -= Ottlll1:t
:3 :::' CocIIJIW , ': Unltl\OWft r~
4=0_ .......
I
..J
!
~g~
f; llrua r.. ,.. . Blood
t 0 Jeane 0'-".
~ lHw TarI ..suib ./Ur, lID 1oUI....~1
1 0 -190 1'Mt. Giwn 5 ::: Amph.-l.l~
J l"'No(Jf'UgK~ 6=f'CP
i 2 . .....ll'WIHl , "" OINt'
~ il J~cocel,. '.Vr\knownTnt
.!, 4=~ tnufts
li____..._ ."
1IIQK""'&lAA..Ql::~
o Dirt
o Otht<
QU,"l'lOlllln
ONat a ,..nsytn"ia
.......
0"'-
COl'\'CIr..tld
0""'"
O:wn i11e~t
@]O
~DO
',........,,----.
ON01. ~..m
o.;w.
OUril~
CDmpl~ce
00"""
OUtllfJOlMtif l'eR
GIwo
[!]O
~
00
--
c--
0"'.....'
""""_..
OTQP
o Ut'lde'LMriq
DTowedU,,1t
0............
AwoIcWloIo~
ONo.~UI
Mantvvtlr
O ".ting-Sk.ld
l14j1fln~l
.,"'... - ... ..'"
o "arlo. ll",,,,
<t.....
UtI_".. mdblot
.... JtoUnd~r\deor
'P.I!II' OVMKf,
VndMidt.
o <om_
Imr\l'doi\
................
. = in fmetgtnC'y
~ hPfK't 1'Wtrt
O!otoI1.(oIl;s1on
ClT""
OUndftUlrn.-
o Tow~ Unit
o UnlMowro
A~ Mlafuvw
. flIcMoidilf'lU!'
1-li~1lI'
Ol'''ln,-~
MArkt.EviderlI
.r"'~.No'Sltid
0......0_
~-
t/1rde"~~
. l+o U"'rich or
-....
"..-....
C CClIftP-:Irtll'll!n.
.........
lMerIaMnr Uu>
. ~;" f""erg~l\(:t'
.".
.....",:-~,._=-=---,-..-
('(llSC I \).l a
Ullllllll~I~RU
W0026860
er.s~ Nurnb' "I
PEIUICCT CGPY
...,.......-
O."in9'Oibef
........
O StIH!rtr\g:.t'Vl_!e
OIC>II....tSI~4ICI
DO"..~..,,~
-.
. Incondlaiw
OSl~al\d'II'k\g OUnll~
~or'>tatt:d
Ul'ldfl"idt,H6
O(ljJrllp~nt
IJJtrulion
O o....ldo. O\!WI
Ve~
l,InCletrldll, Unknown 11
o C~ttn'ltnl 0 L1nd."ide or
lrItNsiof'l UrIlmwl't OWt'ndr
o ~igbl1 RMhihg
o i~1\ Sol6Jdiing
o ...hL.......,.
,...
o UnIlf\Owo
-~...~=--.""'_.'"
0~i1 010
010 ~10
00' OIL)
0'" "0
~1 06 OlD
o .
t-
a 'raking -011-."
.-...
ORNtifUJ-ErideJKt-
or (KN~r 5otat"
o 0dw1 ~..(.
M..-..
o fnconduKvlf
o 5tHiinf _ Iu"~ 0 \,JMnO'fWl'l
~de:nce cr Stned
VAde-ride. "'0
0<_
Intruliol1
o-Ot....
Vct.lcl.
Vnd.rrid.. lJ~lf
OC~\'Nl'lIt D~Of
lntt\JlionUnllf\O'lW'l ~rridr
,
f
0"""'"-'" \
Siren ,
CJ !lireo Soumh~'9 0 U,*1\O'I'Il!f'I ~
~~_~~~'~'~'."""~_'" ._.....1
o li9~'tS ~l'''''irli
hUp:l /www.dot6.state.pa.us/crash.nsflPrint?OpenAgent&a=200515 6280t= 1 u=tmm ullen24
h: J 0 '.l I r: c () . II ~l
8130/2005
J~llnJ JIUr~IUnl ~J~ UJAllr
W,H\ I' :
r.nn, .ne-.gnl-!
I"dgt:: 0 U! 0
Crash Number: W0026860
Incident Number: SIL2005-07-00314
,}:,*":,'-:,:::,',':::,':'
~:-' :'l:J~'rH.~....tt~:
':{:-::":~::',i,ffff~',~.',?~~{
t,,,l~:",~iu L~" J i i
Il2SI ~ . - .. a:JOl .,.
-- --~---~u.ll. --~-
______~ - f 4 C~~!llle
U'"
':>:. ,-,\: ' .s.
c::,,:.',:',;.''''>
~;)a'.~'~_'::~
,~~I~~~"".",;,>
~~~'::)i~:~:'~~:',~~2,~:'~ :/::
.,.
- -L\'ltl--
.. ......:I~
11
,'rc:,:;"~'~'S'i (!)
,;",;"
."~..-,,
"~,:",>'--~:~..,, :
,:f~~~...i!ll't:''Iit.:
.':0..,','."
.. 1* .rktJe R<l.
q ~
_ _ _ _ _ _ ______ _ _ _ - ----Ne~11Olt- - - -
q ~
ILlUSTRATtvfOIHY
SCALEAVAlLAlL'E IN
>>M!lI!JfD.'1O~V ~'E.PORT
1:1
http://www.dot6.state.pa.us!crash.nsflPrint?OpenAgent&a=2005156280t= I u=tmmullen24." 8/3012005
U~ A 12~q"n'l ,~11CA AIU~'IMCI ~A~ U'^'l~ WADI"\ cnn7 "nrln~
77 ~ElEASE OF HAZ t.4AT
Y rl N G tJHK 0
tlOTIFICATIDN OF ACCIDENT INVESTIGATION
SILVEI ?RING TOWNSHIP POLICE OEPAR1,...:NT
6475 Carlisle Pike. Mechanlcsburg, PA 17050
(711) 897-0607
(717) 788-0178
(717) 238-9678
Fu: (717) 786-5984
RE~8LE:
NON.REpORTA8LE:
o
Notice Is hereby given lhatlhe accident indicated below is being invesligated by Silver Spring Township Police Depar1-
ment and thaI the Commonwealth at Pennsyll/an(a Police Accident Report will be sutmitted as pJ85criOed oy Settio!'l
3746(c) 01 the Yehicle Code
This Is a HOH.REPORTABLE accident as prescribed b~ the Vehicle Code. 'The inlormatio!'l submitted below is ab~aif\ed
by the Ofllcer far your convenience in having the proper information lor your Insurance company.
THIS IS THE ONLY INFORMATION THE pOLICE WILL HAYE. NO REpORT WILL 8E MADE.
POUCE INCIDENT t<<JM8ER
l
L.Jo7!
TIME AND OArt Of AcemENT
.D
'7-
, U:05'-
L.OCJ.TION OF ACCIDENT
Co'iBO c..r-IIZ/.:r.s/IZ' Pr/"-E' -
UNIT # I
37 ~i! F V/~ 09
OLER
UNIT #
37 REG. r.=-
P\J,T't ~.
:)8. LEGALLY Y N
PARKE.01 a c
39. PA TITLE OR
OUT.Of.STATE VIM
AO. OWNER
3effA
36. LEGALLY Y N
P.M~KEO' 0 fJ
39. PA TlTLE OR
OUT.or.STATEVlN
40. OWNER
AI.
41.
t<d
'2.
sa.
S9.
80.
61.
6'
67.
ee. CA~RIER
AOORESS
69. crT'f'.SlAlE
& ZIP CODE
70. usoor,
72 VEl<
COHflG.
'S. NO OF
AXLES
II$UWtt
-
UlIIT
DATE OF 0 Ll
81Rn< 7 .
65. DRIVER
Cl,<55
/17
/70/3
63. PriONE
67
68. CAR~IER
ADORESS
69. CITY, STATE
& ZIP CODE
10_ \"~CQT =-
ICCl
fVC If
:CO. P'...'C,
73. CAROO 7". GVW~
800'1 TYPE
76 HAZARDOUS 77. RELEASE Of HAZ MAT
MATERIALS I[j ~['l UNK C
COMPANY
POLICY NO. /'!
72 VEH
CONF1G.
75. NO. OF
AXU.S
73 CA~GO
BODY TYPlO
16 HAZARDOUS
MATERIALS
1'. GVW~
IIllUMllC!
tllfOtlMATlOll
UIIIT
COMPANY
AIi o/JLU.r-D~
POLICY 00,5'1
as DESCRIPTION OF DAMAGED PROPE~TY
7(.,{,,-0770
QWHf;R
AOOfl"E.SS
,,",,"E
AMTTlOtl.Il _now,
SSTPOP!OQ1
EXhlblf L
1)_sr\~ PFV l")~
This is to certify that the information here given is correctly copi9d from an original certificate of death dl~ly filed \vith me as
Local Registra'r. The o'riginal certificate will be forwarded to the State Vital Records Office for permanent filing. '
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
n.._~. ~~~-t"~
Local Registrar
p - 4 ~. r F"; c. 0 F-=
1 ,-'j 1>--_, JUL 1 5 2005
.L .~ '- t.,; 6 y
No. Date
H105.1~A8Y_1191
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTtFICATE OF DEATH
(Coroner)
"''''''''''
w
............
8LACl(lNK
#30-047
SWEfUNVloIBEfI
SOCW.SECURlTYNUM8EA
o.o:rEOFOEKH(UotOh.Day._l
.. July 12, 2005
=
2. Male
NA"'EOFUECEOENT(Fir"._.~
Eric
A
Bishop
,. 201 - 68 - 6515
UNOEI'l'OJI'l" OATEOF8IRTH 8If'.Tli""-"CE(CJyar>d PlACEOFDERH(Cl>od<onyono _insItucllor4""_~
....,..,. "'_ (MOnlIl.Day.~ sw.orfOl,,;gnC<>unlry) HOSJ'l1Al;
Oct.29,1976 Carlisle, FA l~ienlO Ef\fOuIpIIl....O
~ 7. ...
erTY. P \JEATH fACILITYNAMEOfnoti<JSl;jul""'.gIve"'esIandnuml:>el1
UNOER1YEAA
- ~"
g::."jl<t
,~\
Silver Spring 6484 Carlisle
Ie. lid.
DECEDENT'S USU..... OCCUI'IlnON KINO OF BUSINESSIINOUSTRY
IG",.kn:ld_""",,_..- J seph Machin
oI_ldI:>ll".;~not_,oIirlld.l 0 _ - e
l~chinist/.t'rograrrrrer utS Inc.
OEC8)ENrS.......UNG'O'ODAESS{Slr...~.sa...ZipOodel DECEDENT'S
159 Arrry Drive :NCE
...-
1&' Carlisle, PA 17013 ",,_?O?I
M1iE.<l'S NAME" (F.... --'laoII
11. Roi:Jert L. Bi
INFORr.&AHT'SNAME(T~
~ Robert Miller
METHOO OF DISPOSITION
OonatIonO =~"""'ionD __Sla1.0
210.
""
Funeral Heme,
Inc., Carlisle,
ONE SIGNED
~.o.y._l
Cumberland
Pike
MARIT.....SWUS._
--.-'
--
u. Divorced
SUllVMNGSPOUSE
(lI_.,;;...._namel
'-
(1"015+)
".
North Middleton
17..1>>.....__1r
17.._
~
-
M"
a.-nnt:erland \OMIohlp7 17...0 ~"=i':::oI
IolQTIiER.SHAME(F.....-._s...nwne)
II. Faye A. McQuait
-;0051ol~~~~($Ir~~ttg~'7Carlisle,
,,,.
PA
17013
~
~
<I
"
P\..o\CEOFOiSPOSmott-NarNdc.m"""Y.C'....1MOty
._-
LQC..tQlON.~Sl"',ZipCod.
21d.Carlisle, FA 17013
2liestroinster Canetery
NAMEANOAODAESSOFFACllITV
nIWin Brothers
L.lCt:NSENUM8EA
231. 2300.
......SCASEAEFEAAEOTQMEDlCM.EXAA1INBVCOflONER7
~)il
n.
TIMEOFOEArIi prx. DAnPRONQUNCEDOEAO(M~.Oay.~
24. 10:15 P'lol. 25. July 12; 2005
27.,.A/lTI: Enteol"._.............."""'~which......,""'<INiIl_OO""'......""'modooldylng.""""..eaodIacor~relory_._...__..
UoIonIy_"....""_.....
~D
".
!=-=-.
l--dlalII
PART.:
oa-olgnifIcanlo;ondklo"COIIl~Io_.bul
""'......ingin""'~___gMo~inP.vrr1
Aspiration of gasoline
Positional As h ia
OOElO(OAASACONseOUENCE~
Motor Vehicle Crash
OUETQ(ORASACONSEOUENCEQFt.
OUElOlORASACONSEOUENCEO!'l'
T'MEOFINJUflY
Aprx.
.
WERE AUTOPSY FINDINGS
-'lABl-EPRIOATO
COMPlETIONOFCAUSE
OfOEATI4?
MANNEROfOEllnl
O/IJEOf'INJUAY
(MonIh.Oay.""orl
o July 12,2005
03001. 10:15 PM.
O PLACE OF INJUAY.Al-.e.laIm.SVeel.10Cltlly,_
~1Il0.~ Highway
o
~
o
-"
-.
~-
P_r>gl~1k>n
~p(
~D
CWldflOlbOOOl_
SUicklo
...
,... :nb.
CERTWlEfl{O_onIy.,,-,.j
'CERTIFYINGPHYSIClAH(Pt1)'Si1Sa1>.~......_cl___pt>"-nllaopr~_ancIcomplelm"""'23l
Tol"-_loI"'l'kn<>wled~.__"""_I1I_.-<-J_"""""'''sta......
Coroner
o ~1'"
UCENSENUM!lEA DI(fESlGNE"D(Id""".Oay._l
0310. 31d. July 14. 2005
IiAMEANOADOAESSOFPERSONWIlOCOMf'lEreOCAUSEOfDEl\TH
~lBm27)TypAorPrinl Michael L. Norris, Coroner
\t1 6375 Basehore Road, Suite 111
y>{ 32.. Mechanicsburg, Pa. 17050
"
~
~
o
~
>
~
'PFlONOImCINGANOCERTIFYINGPtfYSICIAN(PhysIcian_pr""""ncing_ond~lo"UllIIddeelhl
"to1l.._..'myM-.sg.,dlallloa;u.......Il"-IkM,dohl..nclplacoo,.ncl_10_..ueet.) Inclm_.. 1Jla11l1...
'MEOICAl EXAMINEl'l/CORONEA
~~~";~_~":":'~~~~~~~~: ~~.y.~,:".n.I~~: ~~~~~ ~:':~~ ~~ ~~'.~~: ~.~l~~: ~.~~~~~~~~~l.~~
M..
AEGISTRAR'SSIGw;:rUAEANDNUMBER
~. \''eU-~~-t>J
19.,\ ''<1\ 01
,.,
..,
--
PA
[Xl"bt'-j-- :D
'~
.
WESTFIELD
INS U RA NeE
A member of Westfield GroupSM
Re: Policy Number: APV 1617489
Insured: Darryl P. Nevius Jr.
Policy Period: 4/14/05 to 4/14/06
To Whom It May Concern:
I, Ed Harris, of Westfield Insurance, do hereby certify that the foregoing copy was
prepared under my supervision and to the best of my knowledge and belief is a true and
correct copy of the original policy with an effective date of 4/14/05-4/14/06.
d Harris
anager
Westfield Insurance
Attachment
Sharing knowledge and building trust through insurance and banking.
201 East Oregon Road. P.O, Box 3010. Lancaster, PA 17604.1,800.732.0050. fax 717.569.3480. www.westfieldgrp,com
,
01
o
o
o
o
o
}>
"U
<
~
en
~
....,
..
'"
CD
W
....,
..
w
'"
en
w
o
'"
.
Policy Number: APV 1617489
R T DUNN INSURANCE IN
200 W MAIN 5T
MECHANICSBURG, PA 17055
Name Insured:
DARRYL P NEVIUS JR
101 SILVER SPRINGS ROAD
MECHANICS BURG PA 17050
717-766-0770
DARRYL P NEVIUS JR
101 SILVER SPRINGS ROAD
MECHANICSBURG PA 17050
~
---
=
-
=
=
-
-
=
=
-
- -
Westfield Companies
INSURANCE SINCE 1848
P.O. Box 5001. Westfield Center, Ohio 44251-5001
PERSONAL AUTO POLICY
DECLARATIONS PAGE
.: , Westfield Companies
. P.O. Box 5001 One Park Circle
-. . E Westfield Center, Ohio 44251-5001
'. .'P NEW DECLARATION
EFFECTIVE 04/14/05
.. ~O I.ICY . NUMU~R . . FR~gLI~Y PERIO%< ...... ...... .c:QMPANY' . PROiftoi'NG COVERAGE ..' :.
.
'"
o
o
o
o
o
:P
"U
<
'"
~
'"
....
'"
co
c.J
'"
....
c.J
'"
'"
c.J
'"
o
.
-
--
--
-
----
-'
~
~
~
-
. -
~
~
-
.'=.',='=
APV 1617489
04/14/05 04/14/06
.... ...-...........--.--...---- ...,...,..-.-.-.....--.--.,-,...-,.,.---..,..,...'.............,....,.----..,.,."'.---.
. . ...... NAMEP1NSURED. Afit! A.J:Uii(ESS ;..... . ... .
DARRYL P NEVIUS JR
101 SILVER SPRINGS ROAD
MECHANICSBURG PA 17050
R T DUNN INSURANCE IN
TELEPHONE 717-766-0770
200 \II MAIN ST
MECHANICSBURG PA 17055
PART D - COVERAGE FOR DAMAGE TO YOUR AUTO PROVIDES COLLISION DAMAGE TO RENTAL
VEHICLES UNDER THE DEFINITION OF A "NON-OWNED AUTO". COVERAGE IS LIMITED BY THE
PROVISIONS AND EXCLUSIONS THAT APPI.Y TO PART D. NO COVERAGE IS PROVIDED: (1) IF
WE DO NOT PROVIDE COLLISION COVERAGE FOR ANY "YOUR COVERED AUTO" SHOWN IN THE
DECLARATIONS; (2) FOR LOSS OF USE OF THE RENTED VEHICLE; OR (3) FOR VEHICI.ES
RENTED ON A REGULAR BASIS OR FOR MORE THAN 30 DAYS. DEPENDING ON THE TERMS OF
THE RENTAL CONTRACT, ADDITIONAL LIMITATIONS ON COVERAGE MAY APPLY.
~~------------------------------------------------------------------------------
THIS IS NOT A BILL WIC ACCOUNT NO. 3770027998
DO NOT PAY AMOUNT SHOWN
YOU WILL RECEIVE A SEPARATE MONTHLY BILL ANNUAL PREMIUM $1,093.00
--------------------------------------------------------------------------------
THIS POLICY PROVIDES LIMITED TORT COVERAGE FOR LIABILITY
--------------------------------------------------------------------------------
CREDITS/DISCOUNTS
15Y. PASSIVE RESTRAINT DISC APPLIES TO UNIT 01
STANDARD POLICY INSURANCE SCORE A-07
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
THE POLICY PERIOD BEGINS AND ENDS AT 12:01 AM STANDARD TIME AT THE ADDRESS OF
THE NAMED INSURED AS STATED HEREIN
VEHICLES COVERED
UNIT ST TER YR MAKE-DESCRIPTION VEHICLE ID NUMBER COST-SYM CLASS FACTOR
001 PA 027 93 EAGLE TALON 4E3CFQQEXP3099523 871211 335
--------------------------------------------------------------------------------
PERSONAL AUTO INSURANCE IS PROVIDED ONLY WHERE A PREMIUM OR "INCl." IS SHOWN
FOR THE COVERAGE
COVERAGE LIMITS Of LIABILITY UNIT
A. LIABILITY
BODILY INJURY- $50~000 EA PERSON $100,000 EA ACC
PROPERTY DAMAGE- $~O,OOO EACH ACCIDENT
C. UNINSURED MOTORISTS- NON-STACKED
BODILY INJURY- $50,000 EA PERSON $100,000 EA ACC
C. UNDER INSURED MOTORISTS- NON-STACKED
BODILY INJURY- $50,000 EA PERSON $100,000 EA ACC
BASIC FIRST PARTY BENEfITS:
$5,000 MEDICAL EXPENSE BENEFIT
TOTAL PREMIUM BY UNIT
1
345
566
14
31
137
1093
TOTAL ANNUAL PREMIUM $1,093.00
INCLUDED IN THE TOTAL PREMIUM CHARGE IS A SURCHARGE $124.00
AS A RESULT OF THE MOTOR VEHICLE CITATION
ACCIDENT, OR SURCHARGE AS SHOWN ON THE ATTACHED
PREMIUM SURCHARGE NOTIFICATION FORM, AP111
CONTINUED ON NEXT PAGE
--------------------------------------------------------------------------------
pa e 01 01' 02
2805 (Ed. 09-82)
HF
~ ~ ) \)\-t'
t:f-
,/
1/
I
,
:
~
f
c:l?tfu-0) ct fL,-y~ ^ A)
.'Oi\j',"/c/\LTH OF PF:;>jC~'f12.;~
AFFIDAVIT OF NO OTHER INSURANCE
I, Jeffrey Bobrek, do swear and affirm that:
1. On July 12, 2005, the only liability insurance coverage
that was in effect providing coverage for personal injuries
sustained by Eric Bishop arising out of the automobile
accident on that date was a policy with Westfield
Insurance, which had liability coverage in the amount of
$50,000/$100,000.
2. On July 12, 2005, there was no other Westfield Insurance or
any other insurance company or self insurance which
protected against the risk of liability for personal injury
arising out of the aforesaid accident, including but not
limited to, reinsurance coverage, excess coverage, umbrella
coverage, insurance on any other owned or leased vehicle,
coverage issued to any relative family member, or any other
coverage whatsoever.
fr'
'c. //
' ',/ ,- )
~'&yt- ~~ ~-c{~C
Darryl Nevius
Sworn and Subscrlbed to
before me this \5j~ day
of
iY)fL~
, 200-/J
Notary Public
I'i Notarial Seal ji
Patricia L. Eismann, Notary Public
, City of Harrisburg, Dau hin Conn
LMy Commission Expires ~-.jov. 8, 20~7
+_..,---~-~~- -_.~~-,- "-
My Commission Expires: /1- 8' - 01
---------
. .
. '
~
tAP;;\- r
~
't- ._.~
BOX 2655. HARRISBURG, PA 17105-2655
HOM~ OFFICE.: COWMilUS. OHJO
D1fI. NATIONWIDE
!Jl ~~o~vYe~:~u~j~
Based upon information and belief, this is a true and correct
copy of the policy for policy nwnber :5?Y ~1 1) ':')LJ ')995
as of
7 ~ ) ;) -05
,
'" -'
.".
~.
-.
r '..
PENNRO 1076 7/93
3
(accic(ent date),
/L.l,';":QtI','ilC: ).I'jTUA'c.ltiSUP.,l,:;CE COI,I?A.'IY
I;A~:O,"','ilDC: I,IUTU"-L FI,,:;: IN$Ui'lMIC: CO-'.I?':";/,!,
- ,-- <, ,~, ,...,. ,,~~ "''-''',;:J.1'('(
O NATIONWIDE AUTO POLICY
DECLARATIONS
Page 1 of 2
These Declarations ara a part of the policy named above and Idenmled by policy number below, They
supersede any Declarations Issued ea~ler. Your policy provides the coverages and IIm~s shown In tha
schedula of coverages. They apply 10 each Insured vehicle as Indicated. Your policy complies w~h tha
motorists' financial responslbll~y laws of your state only lor vehicles for which Property Damage and Bodily
InJUry Liability covereges are provided.
Policyholder:
Policy Number: (Named Insured)
56 31 D 545995 ERIC BISHOP
159 NIl( DRIVE
CARLISLEl PA
11013-6603
-
-
iiii
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
'Slued:
MAR 14, 2005
Polley Period Fro",:
APR 01. 2005 to OCT 01, 2005 but only If the required premium br this period has been paid and only for
six month renewal periods" ranewal premiums h....e been p.ld as required. This policy Is In~lally effective at (1)
the time the application for Insurance Is completed, or (2) 12:01 a.m. on the first day of the policy period, whichever
Is later. Each renewal period begins and ends .t 12:01 ..m. standard lime at the eddress of the named Insurad
stated her.ln. This policy cancels et 12:01 e.m. .tlhe address of the n.med Insured atated herein.
.
o
IMPORTANT MESSAGES:
THE FOLLOWING CHANGE(S) HAVE BEEN MADE TO YOUR POLICY:
EFFECTIVE APR 01, 2005
-CHANGED RESIDENTIAL TERRITORY
SEE ENCLOSED NOTICE FOR PREMIUM DETAIL
I
I
!
INSURED VEHICLE(S) & SCHEDULE OF COVERAGES
p
1. 1991 PLYM BREEZE
Coveragea
COMPREHENSIVE
COLLI S I ON
PROPERTY DAMAGE LIABILITY
BODILY INJURY LIABILITY
UN I NSUREO MOTOR I STS - BOO I L Y INJURY
UNOERINSURE9 MOTORISTS-BODILY INJURY
TO1\' I NG AND LABOR
FIRST PARTY BENEFITS
OPTION 1-MEOICAL BENEFIT
OPTION 2-INCOME LOSS BENEFIT
OPTION 4-FUNERAL BENEFIT
liMITED TORT
INSURED DRIVERS:
Driver
If Name
01 ERIC
B I SHOP
V-100-A
FRAME: C 20
10 11P3EJ46C7VN716S62
L1m~a or Llabll~y
ACTUAL CASH VALUE LESS $ 100
ACTUAL CASH VALUE LESS $ 500
I 100,000 EACH OCCURRENCE
100,000 EACH PERSON
300AOOO EACH OCCURRENCE
(NON-"TACKEOl ..
$ 100,000 EACH PERSON
$ 300AOOO EACH OCCURRENCE
(NON-"TACKED)
I 100,000 EACH PERSON
300,000 EACH OCCURRENCE
50 EACH DISABLEMENT
I
10,000
5.000 TOTAL
1.000 MONTHLY
2,500
Birth
Oete
10/29116
Marlta'
Statua
DIVORCED
L1cenae
Number
24356162
;1
'-i'
SIx Month
Premium
I 41,10
116.40
62.90
$ 65.50
$ 5.60
i 26.60
1.60
$ 22.50
i 4.10
.20
TOTAL $ 372.90
ft.hi bit G
. .
POWER OF ATTORNEY AND FEE AGREEMENT
BY SIGNING TIllS AGREEMENT, I (WE) ACKNOWLEDGE THAT I (WE) HAVE ENGAGED THE LAW FIRM OF
NA VITSKY, OLSON & WISNESKI LLP (HEREINAFI'ER NOW), TO REPRESENT ME (US) UNDER THE FOLLOWING
TERMS AND CONDITIONS:
1. NOW may on my (our) behalf secure medical, work and other similar records, conduct an investigation, negotiate, and if . _
necessary start suit a~t anyone responsible for my (our) injuries and losses with respect to I-/~-".r A ~7'7> IJcCif2IJ<JI
I^Vrivl'j. ~c. P" 51, 0 . with full power and authority to appear on behalf of the undersigned In any Court of record
or in any administrative or other proceeding, to do and perfonn all and every act and thing whatsoever that may be requisite
and necessary to be done in connection with the above claim as fully as the undersigned might or could do if personally
present; hereby ratifying and confirming all that said attorney shall lawfully do or cause to be done therein by virtue of this
power of attorney.
2. I (we) understand that so long as the case is handled by a NOW attorney, I (we) will not be responsible for any fees and/or
expenses unless a recovery or benefit is obtained.
3. !fmy (our) case is handled to a successful completion by a NOW attorney, I (we) agree to pay NOW all reasonable out-<lf-
pocket expenses without the payment of interest, plus a fee for time expended as follows:
ME
NOW LLP
a. SETTLEMENT PRIOR TO STARTING SUIT
b. SETTLEMENT FOLLOWING SUIT BUT PRIOR TO TRIAL OR
ARBITRATION
c. SETTLEMENT OR VERDIer AT TRIAL OR ARBITRATION,
AFTER TRIAL, ARBITRATION, OR APPEALS OR SHORTLY
BEFORE TRIAL AND AFTER CASE HAS BEEN TOTALLY
PREPARED
d OTHER CASES
70%
30%
65%
35%
60%
40%
4. !ffor any reason I (we) take my (our) case to another attorney or law firm or handle it myself (ourselves), I (we) recognize
that NOW has, in good faith, expended money and time for my (our) benefit and I (we) therefore agree to pay, or have my
(our) new attorney pay, immediately, upon severing the NOW attorney/client relationship, all the out-<lf-pocket expenses
incurred on my (our) case plus interest at the rate of 6% per annum from the date of each expenditure. In addition, when
the case is successfully conclnded, I (we) agree to payor to direct my (our) new attorney to pay as a fee 20% ofthe gross
recovery to NOW.
5. In the-evenLthaL3Il)'-settlementkn1alk!lailitntG!!!ml or geferred~!ll I,asis,l<i>F ~i!3ll: ])e5~lid:d to receive their
percentage based on the present value of the structured settlement, if paid as a lump sum at the time of settlement -
I (we) agree not to settle or discuss settlement of my (our) case without the written consent of NOW.
BY SIGNING TIllS AGREEMENT, TIllS 1012- DAY OF ft~<..IT- .20"$71 (WE) ACKNOWLEDGE THAT! (WE)
HAVE READ, UNDERSTOOD, AND RECEIVED A COpy OF SAME AND AGREE WITH ITS TERMS AND CONDmONS.
WITNESS(ES):
n~ Q. ~~
CLIENT(S):
Rilia
~
o.J-,W\ Tr "'1(tEAt
b<'<" e,\~l."op ~~T,,-Te, I
(SEAL)
f)<~lhd- H
~
<'>'
~
'"
;;;
Ill'
0<"> <">
00,0
dei ci
0.... ....
N<"> <">
0'0
'" '"
u-i ui
'" '"
'"
o
..;
.,
'"
gig'
~I~i
"'-',..-1
'"
C!i
<">
::\'
0<"> <"> 0 0 0 0 81 '"
00 0 '" '" l,{) lO; 0
c::ici 6 on on r--:I""': ~I ..;
0.... 'I'- "', '" ~,~i .,
C N~ <"> '" '"
~ ,
0
E
<(
ro ~
>
0 e "
E "- :E
" " "- "
::;; " <( >
:E " "-
"'" ~ 0
0> 0 r.
U '"
"-- iD
a. "'0 e
...J 00", E '0
,.,'"
...J 1:: '" '" c '"
"-" ~ c
:i: 0 0 ~ .~
,,~ a; 0
m Q. <(0- 0- >-
<Il Q)
l: 0:: en :v
m c: c 0
~ Q) 0 e E ;;
., 0 e <(
III u " U 0- '"
O/S c: .. E c8 i?:' '"
Q) en ~
l: c: ", c c ~ ~
Q... Z ~ ~ ~
0 o ~ 0 0
)( ~ 1l u '" u >-
m l- e ~ "
0 W ~ . ,,- " <;
<t 0 ~ '" ~
"''' .!!' .c
.- III " .~ :v ro
:-.c: " c .c I
~ Q) .co E "
E~
m ~ '" ~ '"
.... (,) UZ U ~
'S;
11l
Z LLiw UJ ui
co '0 '0
" 22 2 '"
E '" '" .!!' "
.. Uiiii '" ;;
Z UJUJ UJ UJ
cia: ci. ci.
00 0 0
r.r. " "
"'''' '" '"
miIi iD iIi
E. <">1'- 1> '"
~ "'<"> ;::
z, "'" :;;
1'-1'- I'-
'"
'"
'" '"
"'", ~
'" <0 0
2 "0"' "- 0 0
"'00 X 0 ~
.. ~NO i'J
0' ~(;:)~ UJ ~ '"
C 0 - ~ C
" XNI'- 0 i!J 0 '"
<.> w-- ~ ~ '" '" " >
"'''' C "
~ C 0 ~ <(
.. .2 g! .. u 0 '"
> ;; 1;; '" " 1] ;;
'C -;; " 0 ~ ~ 0
<( CO > (J '" '" U
1;; :; E CO u:: Q; ~ c
'" 0 " ~ <.> .~
(J > <( III '" LL
"- E 0 u:: 0 :E 0 0
~, c 0 0 0
.~ <"> <"> <"> 0
<( "'''' ~ III '" LL '"
U 0
0 U u ro 0 u ro 0 u ro <">
<:> "" (5 0 " (5 0 " (5
'" '" "" '" " <"> "
::;; 0 ~ UU f- ~ U f- ~ U f- ]i
g 0 ....
<1 0 '" 0 ;'!
., ~ ~ f-
" .. 0
in 0 f-
"
0>
..
Q.
;:;xhl b;+ L
~
;r
iD
=4
-
-
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
Po Box 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
WEB ADDRESS www.state.oa.us.
March 28, 2006
David S. Wisneski, Esq.
Navitsky, Olson & Wisneski LLP
2040 Linglestown Rd. Ste. 303
Harrisburg, PA 17110
Re: Estate of Eric Bishop
File Number: 2105-0805
Court Number: Not Known
Dear Mr. Wisneski:
The Department of Revenue has received a letter concerning the Petition for Approval of
Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful
death and survival action. It has been forwarded to this Bureau for the Commonwealth's
approval of the allocation of the proceeds paid to settle the actions.
Pursuant to the letter, the 28-year-old-decedent died as a result of a motor vehicle
accident. Decedent's wrongful death beneficiaries are his two minor issue.
Please be advised that, based upon these facts and for inheritance tax purposes only.
this Department has no objection to the proposed allocation of the net proceeds of this action,
$134,426.97 to the wrongful death claim and $0 to the survival claim. Proceeds of a survival
action are an asset included in the decedent's estate and are subject to the imposition of
Pennsylvania inheritance tax. 42 Pa. C.S.A. 98302; 72 P.S. 999106,9107. Costs and fees
must be deducted in the same percentages as the proceeds are allocated. In re Estate of
Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995).
J trust that this letter is a sufficient representation of the Department's position on this
matter. As the Department has no objections to the Petition. an attorney from the Department
of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court
has any questions or requires anything additional from this Bureau. Finally, the approval of this
allocation is limited to this estate and does not reflect the position that the Department may take
in any other proposed distribution of proceeds of a wrongful death I survival action.
Sincerely,
dJ }\.-(Cei'\.-~-to(\ Ie
Holly A. McClintock
Trust Valuation Specialist
PHONE: 717-787-1794 . FAX: 717-783-3467 . <MAIL: hmcclintoc@state.oa.us
-----
ftZ~)blt J
AFFIDAVIT
I, AMY BISHOP, do hereby Swear and Attest as follows:
I, Amy Bishop, am an adult. I am the mother and guardian of Collin Bishop and Tessa
Bishop, who reside with me at 7816 Wertzville Road, Carlisle, Pennsylvania. I have read the
Petition for Court Approval of Decedent's Compromise Settlement and Distribution of Proceeds
pursuant to Pa. R.C.P. 2206 in the Estate of Eric Bishop v. Darryl Nevius case, and I join in the
Administrator of Eric Bishop's Estate's request that the Court approve the compromise
settlement and distribute the proceeds in accordance with the terms of the Petition. I also desire
and request that the Court direct that the net settlement proceeds due to Collin Bishop and Tessa
Bishop be placed into structured settlements with Prudential Insurance Company of America as
set forth in the Petition.
Date: 1 I (p lOG
'!
Sworn to and subscribed before me this
ly ~day of ~1A.L
,2006.
--d~~ 0 ~~
Notary Public
H OF PII N
Notarial s..I
MolluoA. MIlltr, NotIl1Pa1l1lt
N.... Mlddt_ 'I'wp" CumborImoIC'aIIII1
I My('_~~.~Moyl"2OOI
M""fI~r, P~'.I!'\~I!~",:{'d, ,l\lRl1.:lC)tttlon ofNot:IItee
:,
fK~\br+ i~
'PR1
MAR 29 21eU:> 14:';9 r~ r~~-LLLUI'll:lLb Lt1
t:::fI1t::l':11b'::Hb'( I U R~l (1 (-:;)'fl~.:XJb r. tJo::::" t:J.::::
Today's Date:
March 29, 2006
Plan #2
A. Benefits for Tessa Bishop, Female,
Born 08/08/1997, Age 8.
Guaranteed
Amount:
Guaranteed LumD Sum Benefits:
Payable - 08/08/2015 (age 18).
Payable - 08/08f2018 (age 21).
Payable - 08f08f2022 (age 25).
Payable - 08/08/2027 (age 30),
LUMP SUM TOTALS:
$30,000.00
$31,372,17
$38,000.00
$40,000.00
$139,372.17
$139,372.17
Tessa Bishop Total:
B. Benefits for Collin Bishop, Male,
Born 06/1812001, Age 4.
Guaranteed Lumo Sum Benefits:
Payable - 06/18f2019 (age 18),
Payable - 06f1812022 (age 21).
Payable - 06/18/2026 (age 25),
Payable - 06f18/2031 (age 30).
LUMP SUM TOTALS:
$38,650,65
$40,000.00
$45,000,00
$48,000.00
$171,650.65
$171,650,65
$311,022.82
$15,583,03
$326,605,85
Collin Bishop Total:
TOTAL STRUCTURE AMOUNT:
Attorney Fees and Expenses:
TOTAL PLAN AMOUNT:
The Internal Rate of Retum is approximately 5,12% and
the Tax Equivalent Yield is 7,31%, based on a 30% tax bracket.
Cost;
$67,208.49
$67,208.49
$67,208.48
$67,208.48
$134,416.97
$15,583.03
$150,000.00
This proposal is effective through APRIL 3, 2008. This is the date that the funds for the
structure must be at the annuity company or this proposal will expire.
This is an illustration, not a contract.
w~ TnTnl c~r.c ~~ wW
-
,
-------------
.
.
f )(~\ brt l
.
.
,
fI FINANCIA.L SETTLEMENT SERVICES
Providing StruCfured Solutions.
..
DATE:
As of July 2005
Financial Settlement Services (FSS) Clients
TO:
SUBJECT:
Prudential Ratings
The following is a summary of the current ratings for Prudential Insurance Company of
America. Prudential is a highly rated company by the various rating organizations,
This Prudential case would include a Qualified Assignment to Prudential Assigned
Settlement Services Corporation ("PASSCorp"), Financial Settlement Services will
request a Statement of Guarantee from Prudential Insurance Company of America
guaranteeing the obligations assigned to PASSCorp. This guarantee is issued with the
policy and is not part of the Release and Qualified Assignment.
Prudential Insurance Company of America ratings are as follows:
Rating Organization Prudential Insurance Company
of America
A. M. Best Rating & Size A+ (XV)
Moody's Aa3
Standard & Poor's AA-
Filch AA.
Should you need any additional information, please call FSS (800) 993-9931.
FIl'fANC'AL SmuMENT SERVICES
ONE NATIONWIDE PLAU. 02-02-05, COL\IMBUS. OH ')215
VOICE (800)993-9931' FAX (614) 249.2013
~ n -l(),
'7'- Irt
l:l
lI( ('; r-....,
~ ,
...... CJ (.,:-'
~ '0 )"'0 '~J ~
-
\'- C ,
rS - ..,^.-
r r....,:;
(
J C" .,'l
-~-
\D
J
ROBERT L. MILLER, as Administrator of
ESTATE OF ERIC BISHOP, Deceased,
: ~RECEIVl. :'j
,
APR 1 8 7006
IBY:_.~_i
COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
,
Defendant
CIVIL ACTION - LA W ~
NO.Ot., -,J6L.-S G()~l IStL~
PETITION FOR APPROVAL OF
WRONGFUL DEA TH/SURVIV AL
ACTION SETTLEMENT PURSUANT
TO Pa.R.C.P. 2206
Plaintiff
v.
DARRYL NEVIUS,
ORDER
t\..
AND NOW, this I eo. day of
1\ y rJ
, 2006, upon consideration of
the attached Petition for Approval of Decedent's Compromise Settlement and Distribution of
Proceeds Pursuant to Pa. R. c.P. 2206,
IT IS HEREBY ORDERED THAT:
I) Settlement of the above-captioned action by Robert 1. Miller, as Administrator of
the Estate of Eric Bishop, deceased, in accordance with the terms of the Petition, is hereby
ratified and approved. Robert 1. Miller is authorized to sign a Release and mark the above-
captioned action settled, discontinued and ended as to Defendant.
2) All settlement proceeds shall be distributed as follows:
a)
The Estate of Eric Bishop
Wrongful Death allocation (100% of settlement
proceeds)
$134,426.97
Survival Action allocation (0%) of settlement
proceeds)
$ -0-
b)
Navitsky, Olson & Wisneski LLP legal fees
(10% of settlement proceeds)
$ 15,000.00
c)
Navitsky, Olson & Wisneski LLP
reimbursement of expenses
$
573.03
TOTAL
$150,000.00
3) Pursuant to Pennsylvania's Intestacy Law, the One Hundred Thirty-Four
Thousand, Four Hundred Twenty-Six Dollars and Ninety-Seven ($134,426.97) Cents in
Wrongful Death proceeds shall be equally divided between the decedent's issue, Collin Bishop
(Sixty-Seven Thousand Two Hundred Thirteen Dollars and Forty-Eight ($67,213.48) Cents) and
Tessa Bishop (Sixty-Seven Thousand Two Hundred Thirteen Dollars and Forty-Nine
($67,213.49) Cents) and shall be placed in structured settlements with Prudential Insurance
Company of America that will provide for guaranteed payouts as follows:
Date
Payment
Collin Bishop (DOB: 06/18/01)
06/18/2019 (age 18)
06/18/2022 (age 21)
06/18/2026 (age 25)
06/18/2031 (age 30)
$38,650.65
$40,000.00
$45,000.00
$48,000.00
$171,650.65 Total
Tessa Bishop (DOB: 08/18/97)
08/08/2015 (age 18)
08/08/2018 (age 21)
08/08/2022 (age 25)
08/08/2027 (age 30)
$30,000.00
$31,372.17
$38,000.00
$40,000.00
$139,372.17 Total
BY THE COURT:
~ 1. U-\~
J.
~
o
~'
o\~
2
:;
RECEIVED MAY 23 Y
ROBERT L. MILLER, as Administrator of
ESTATE OF ERIC BISHOP, Deceased,
COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
Plaintiff
CIVIL ACTION - LAW
NO. 06-2065
v.
Defendant
PETITION FOR APPROVAL OF
WRONGFUL DEATH/SURVIVAL
ACTION SETTLEMENT PURSUANT
TO Pa.RC.P. 2206
DARRYL NEVIUS,
AMENDED ORDER
AND NOW, this 1. C. t\\ day of
f\\ b.. '\
, 2006, upon consideration of
the attached Amended Petition for Approval of Decedent's Compromise Settlement and
Distribution of Proceeds Pursuant to Pa. RC.P. 2206,
IT IS HEREBY ORDERED THAT:
1) Settlement of the above-captioned action by Robert L. Miller, as Administrator of
the Estate of Eric Bishop, deceased, in accordance with the terms of the Amended Petition, is
hereby ratified and approved. Robert L. Miller is authorized to sign a Release and mark the
above-captioned action settled, discontinued and ended as to Defendant.
2) All settlement proceeds shall be distributed as follows:
a)
The Estate of Eric Bishop
Wrongful Death allocation (100% of settlement
proceeds)
$134,416.97
Survival Action allocation (0%) of settlement
proceeds)
$ -0-
b)
Navitsky, Olson & Wisneski LLP legal fees
(10% of settlement proceeds)
$ 15,000.00
c)
Navitsky, Olson & Wisneski LLP
reimbursement of expenses
$
583.03
TOTAL
$150,000.00
3) Pursuant to Pennsylvania's Intestacy Law, the One Hundred Thirty-Four
Thousand, Four Hundred Sixteen Dollars and Ninety-Seven ($134,416.97) Cents in Wrongful
Death proceeds shall be equally divided between the decedent's issue, Collin Bishop (Sixty-
Seven Thousand Two Hundred Eight Dollars and Forty-Eight ($67,208.48) Cents) and Tessa
Bishop (Sixty-Seven Thousand Two Hundred Eight Dollars and Forty-Nine ($67,208.49) Cents)
and shall be placed in structured settlements with Prudential Insurance Company of America that
will provide for guaranteed payouts as follows:
Date
Payment
Collin Dishon (DOD: 06/18/01)
06/18/2019 (age 18)
06/18/2022 (age 21)
06/18/2026 (age 25)
06/18/2031 (age 30)
$38,650.65
$40,000.00
$45,000.00
$48.000.00
$171,650.65 Total
Tessa Dishon (DOD: 08/18/97)
08/08/2015 (age 18)
08/08/20 18 (age 21)
08/08/2022 (age 25)
08/08/2027 (age 30)
$30,000.00
$31,372.17
$38,000.00
$40.000.00
$139,372.17 Total
BY THE COURT:
'ov
:/:p
D
J.
2
\7'JI\j,:ih"l/. ~'\N:l (-I
).. I " ,,'<r~,,-' ,. ,~, , .:;..c.::..'.'.'nl"\
'.,..L1'~1 L,' "-:!'L V
01 :8 !,W 08 A \f!;J 900l
'w.c".'" "t'" ""'Hi:.lO
^, : 11 "t\ II-I! 1 ),"--1'0"- -I '
_ .,......,r ,.....,......,...-' ....l
3~)1.:!:iO.0311:1
ROBERT 1. MILLER, as Administrator of
ESTATE OF ERIC BISHOP, Deceased,
Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
CIVIL ACTION - LAW
NO, 06-2065
v,
Defendant
PETITION FOR APPROVAL OF
WRONGFUL DEATH/SURVIVAL
ACTION SETTLEMENT PURSUANT
TO Pa.R.C,P, 2206
DARRYL NEVIUS,
PRAECIPE TO DISCONTINUE
TO THE PROTHONOTARY OF CUMBERLAND COUNTY:
Please mark the above-captioned action settled, ended and discontinued.
Respectfully submitted,
NA VITSKY, OLSON & WISNESKI LLP
---
J1~)
I.D, No. 58796
2040 Linglestown Road, Suite 303
Harrisburg, PA 17110
717/541-9205
Counsel tor Plaintiffs
Date: August 28, 2006
cc: Robert 1. Miller
Amy Bishop
James Bogar, Esquire
Lisa Kircher/Westfield Ins.
Steve Turoczy/Nationwide Ins.
o
G
-<'-....
""1';(1:','
rn.\";
Z."
;<L
(fJ
..,'
'~~;
:."3
-,
....,
=
,;;;;;,:;;>
0--
(/)
,..,.,
-<:,
I
c:r>
:r>'
:::~
-
o
'T1
.-4
:L-n
rt1p
-fJ'''TI
(';1:::_/
~:>~ (:;1
~L -,'c
~::~(,~
.t<")
::::,
~J
:<
CD