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,
'GRAHAM & MAUER, P.C.
By: Lisa J. Mauer, Esquire
ID # 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, PA 19482
(610)933-3333
Attorney for Petitioner
CUMBERLAND COUNTY COURT OF COMMON PLEAS
In re: JOSHUA TRAVERS, a minor
No. O~ - ,26:1.. Y
CI~lL~~
PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTION
TO THE HONORABLE JUDGES OF THE SAID COURT:
Your Petitioner, Bridgette Travers, parent aI}d natural guardian of a minor, Joshua
Travers, respectfully represents that:
1. She is the parent and natural guardian of Joshua Travers, a minor, whose date of
birth is November 29, 1996, and who was involved in a motor vehicle accident on June 11,
2004.
2. Joshua Travers, a minor, currently resides with his mother, Bridgette Travers
at II Longstreet Drive in Carlisle, Pennsylvania.
3. This Petition is brought in Cumberland County, the county in which the Travers
family resides.
4. The accident occurred when Bridgette Travers, the driver of the vehicle in which
Joshua Travers was a passenger, lost control, causing a collision with another vehicle.
5. As a result of the aforesaid motor vehicle accident, Joshua Travers was life
flighted to Peninsula Regional Medical Center where he was stabilized before being transported
to University of Maryland Medical Center where he was an inpatient from June 12 - 16,2004.
,
6.
Nationwide Insurance Company, Petitioner's automobile insurance carrier,
insured Joshua Travers for $5,000.00 in medical benefit coverage, which has now been
exhausted. (See Nationwide first party payout ledger attached hereto as Exhibit A.)
7. Counsel was retained upon a twenty-five (25%) percent contingent fee basis by
Petitioner. In addition, counsel has incurred the following expenses:
University of Maryland Medical Ctr. (medical records) 119.52
Penninsula Regional Medical Ctr (medical records) 44.86
Adams Photography (photographs of scarring) 180.20
Staples (copy medical records) 11.20
Delaware State Police (accident report) 12.50
Penninsula Regional Medical Ctr. (medical bills) 10.00
Smart Docs - Penninsula Orthopedics (medical records) 23.27
Cumberland County Prothonotary (Minor's Compromise) 55.50
457.05
8. Subsequent to the exhaustion of the medical benefits on Joshua Travers'
auto insurance policy, a portion of his accident-related medical bills were paid by the
Pennsylvania Department of Public Welfare, which has agreed to reduce their lien from
$15,916.54 to $10,611.56. (See Department of Public Welfare Claim Summary attached hereto
as Exhibit B.)
9. After exhausting the Nationwide medical benefits, Petitioner incurred additional
medical bills which remain unpaid (see unpaid medical bills attached hereto as Exhibit C):
Penninsula Regional Medical Center
Transcare Harford County (reduced from $2475.00)
Trauma Surgical Associates
Emergency Services Associates (reduced from $646.00)
16.34
500.00
375.00
450.00
1)41.34
10. Nationwide Insurance Company, insurer of the tortfeasor, has offered
$100,000.00 to settle Joshua Travers' personal injury claim.
11. The settlement will be structured as follows:
- Cash at time to settlement (for attorney's fee,
costs, unpaid medical bills, DPW lien and a
restricted bank account, which will be
available in the event Joshua Travers requires
additional medical treatment prior to his 18th
birthday.
$47,409.95
- Lump sum paid to Joshua Travers on 11/29/2014
$78,393.72
12. The rating of structure guarantor, Hartford Life Insurance Company, by AM.
Best is A+ (superior). (See attached rating sheet attached hereto as Exhibit D.)
13. Petitioner approves the proposed settlement for Nationwide's policy limits, and
further approves the proposed distribution set forth in the proposed Order attached hereto.
WHEREFORE, Petitioner prays that an Order be entered approving the compromise
allowing counsel fees and costs and ordering distribution.
Respectfully Submitted,
By:
Date: ~ r5 .Gle
,
GRAHAM & MAUER, P.c.
By: Lisa J. Mauer, Esquire
ID # 65426
The Commons at Valley Forge
Suite 22, P.O Box 987
Valley Forge, PA 19482
(610)933-3333
Attorney for Petitioner
CUMBERLAND COUNTY COURT OF COMMON PLEAS
In re: JOSHUA TRAVERS, a minor No.
ATTORNEY VERIFICA nON
In my professional opinion as counsel in this matter, I believe the proposed One Hundred
Thousand ($100,000.00) Dollar structured settlement is reasonable under the circumstances.
GRAHAM & MAUER, Pc.
By:
Date: L\_.
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.
GRAHAM & MAUER, P.C.
By: Lisa 1. Mauer, Esquire
ill # 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, PA 19482
(610)933-3333
Attorney for Petitioner
CUMBERLAND COUNTY COURT OF COMMON PLEAS
In re: JOSHUA TRAVERS, a minor No.
AFFIDAVIT OF GUARDIAN
We, Carroll 1. Travers, Jr. and Bridgette Travers, certify that:
1. We are the parents and custodians of Joshua Travers; and
2. We approve the proposed One Hundred Thousand ($100,000.00) Dollar structured
settlement and the distrib tion thereof.
(J
Carroll 1.
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Bridgette T !Wers
om to and Subscribed before me this J day of NPn' /
,2006
COMMONWEALlH Of !"ENNWLVAN,^
NOTARI;l-lsEAl--.----::l
DAWN M. SHUGHART. Notmy Public I
Boro of Call1sle, Cum be/land Coun1y
My Commission Expires Nov. 28, 2006
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
CASUALTY UNIT
P.O. BOX 8486
HARRISBURG, PA 17105-8486
September 19, 2005
GRAHAM & MAUER PC
LISA J MAUER ESQUIRE
THE COMMONS AT VLLY FORGE STE 22
POBOX 987
VALLEY FORGE PA 19482
Re, JOSHUA TRAVERS (minor)
CIS #, 410209434
Incident Date, 06/11/2004
Dear Attorney Mauer:
The Department of Public Welfare maintains a lien in the amount of
$15,916.54 for the above-referenced incident.
The Department has agreed to reduce its lien by 1/3% and accept the net
payment of $10,611.56 to satisfy the total lien amoun~
Checks should be made payable to the Department of Public Welfare and
sent to my attention at the above address. We request that with all
transmittal of funds, you provide the Department with a copy of the final
distribution sheet.
In the event you have already brought or will bring any action resulting
in a further recovery, we reserve the right to seek recovery of any
additional unpaid portion of our medical/cash lien. This settlement in no
way affects our future rights.
Thank you for your cooperation in this matter.
questions, please contact me.
If you have any further
Sincerely,
)X4A.~L.~
Margaret L. Sohn
Claims Investigation Agent
717-772-6609
717-705-8150 FAX
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1\011. PlHl)t$\JVl'S MOST COIlU'Ull MIDICAl. Cunn
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'MEDICAL CEN1ER D 1 06/03/05
p"rt of PeninSuJiI Re<<jonill HeilltnSyslem
'no East Carroll Street. Salisbury. Maryland 21801 4~O-543.7436 or 1-800-235-8640 SERVICE FROM iHROUGH
\..-- 06/11/04 p6/11/04 I
PERSON R~SPONSIBLE Pil,TIENI IE Tc
JOSHUA TRAVERS
BRIDGETTE TRAVERS ACCOUNT NUM8ER BIHTHDATEfAGE 6 I
11 LONGSTREET DRIVE 2001272485 11/29/97
CARLISLE, PA 17013-0000 ADMISjON DAj'TIME DISCHARGE Oil.TE / / 1ST/>,..,.
06 11 04 18: 29 06 11 04 00:00 0
GU~~~U~Cf619 fi"'!'YVf]JBE - 9 8 5 3 H1ST~tl'~!l 0 619 I
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INSURANCE NUMBER INSURANCE DESCRiPTION INSURANCE RANK (1-8ILL FIRST)
8101 PIP NO FAULT 1
ITEMIZED (DETAIL) BILL
DATE ITEM# DESCRIPTION QTY AMOUNT
06/11 222076 BUN 1 12.50
06/11 222106 ELECTROLYTES 1 12.50
06/11 222157 GLUCOSE, FASTING 1 8.50
06/11 223004 CBC W/DIFF 1 10.50 i
06/11 229069 RED CODE PEDIATRIC URINALYSIS 1 28.50 I
06/11 251016 TYPE AND SCREEN 1 21.00 I
06/11 253013 PROTHROMBIN TIME 1 15.00
\ '- 06/11 253097 PTT-SCREENING 1 16.00
**300 LABORATORY 124.50
06/11 321310 TRAUMA C-SPINE 3 VIEW PORT W/COLLAR 1 46.25
06/11 322331 PORTABLE-CHEST 1 46.25
06/11 326313 FOOT-PORTABLE 1 46.25
06/11 326613 LEG-PORTABLE 1 46.25
06/11 326614 LEG-PORTABLE - 1 46.25
06/11 326661 PELVIS-PORTABLE 1 69.25
**320 RADIOLOGY/DIAG 300.50
06/11 364101 CfT-HEAD SCAN W/O CONTRAST 1 164.00
**351 CAT SCAN HEAD 164.00
5~~~~1/04 o~111/04
\ !"[ \
\"T1;],bSHUA TRAVERS
\ ACCOU~T BUCl"f~ 72 4 8 5 - 0 1
'1'EDERAL TAX NUMBER #52-0591628
PLEASE KEEP THIS BILL FOR FUTURE REFERENCE
CHARGES MAY BE ADDED TO YOUR ACCOUNT AS A RESULT OF SERVICES PROVIDED BEFORE DISCHARGE BUT BILLED AT A LATER DATE
PA-1 05 ~9/02)
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MEOICA.l CENTER D 2 06/03/05
P~rtolPenmSlJljRegionalHeaJlhSystem
l,QO East CarrQt! Stree~. Salisbul)" Marylano 2,8Qi 4'0.543.7436 or '.800.235.8640 SERVICE FROM THROUGH
\-. 06/11/04 P6/11/04 I
PERSON R::SPONSIBLE PATIENT I E 1c
JOSHUA TRAVERS
BRIDGETTE TRAVERS I\CCOlJNl N1jMBER BlRTHr~i'~ 9/97 61
11 LONGSTREET DRIVE 2001272485
CARLISLE, PA 17013-0000 ~~n5'r&4 il~fHARGE DATE / / I STAY
18: 06 11 04 00:00 0
GU~'1l'l'J ~lf(f619 rr'iR17'!r5'& - 9853 HIST~Ycl'I'l'~'13 0 619 I
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INSURANCE NUM8ER INSURANCE DESCPiPTION INSURANCE RANK (1-8ILL FIRST)
8101 PIP NO FAULT 1
ITEMIZED (DETAIL) BILL
DATE ITEM# DESCRIPTION QTY AMOUNT
06/11 360102 C/T-ABDOMEN W CONTRAST 1 165.25
06/11 362102 C/T-THORAX SCAN W CONTRAST 1 165.25
06/11 365102 C/T-PELVIS SCAN W CONTRAST 1 165.00
06/11 368201 C/T-C SPINE w/o CONTRAST 1 165.00
06/11 369203 C/T-3D/MULTIPLANAR RECONSTRUCTION 1 62.50
**352 CAT SCAN BODY 723.00
\'-' 06/11 203550 ER - SCREENING 1 35.00
**451 ER MEDICAL SCREENING 35.00
06/11 203300 ER - COMPREHENSIVE VISIT 1 278.00
**452 ER BEYOND SCREENING 278.00
06/11 420419 PROMETHAZINE AMP 25MG/ML 1 .45
06/11 423045 CEFAZOLIN IG/VIAL 1 7.37
06/11 425047 MORPHINE SULFATE 2MG TBX 3 1. 50
**636 DRUGS REQ HCPCS II 9.32
TRAVERS
S'(JvsYf1/ 0 4
15~'1h/04
~
Im'i'lbSHUA
I 'CC~Ta'tl'l'2 72 4 8 5 - 0 1
'reDERAL TAX NUMBER #52.0591628
PLEASE KEEP THIS BILL FOR FUTURE REFERENCE
CHARGES MAY BE ADDED TO YOUR ACCOUNT P.S A RESULT OF SERVICES PROVIDED BEFORE DISCHARGE BUT BILLED AT A LATER DATE.
PA.l0519....02)
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. . . TYPE OF BilL PAGE CHARGES PROCESS THRU
"MEDICAL CENTER D 3 06/03/05
Part of Pen,nsula Regional Healtl1Syslem
100 East Carroll Street. Salisbury, Maryland 21801 410.543.7436 or 1.800-235-8640 SEAVlCEFROM THROUGH
........ 06/11/04 6/11/04
PERSON ReSPONSIBLE PATiENT IE Ic
JOSHUA TRAVERS
BRIDGETTE TRAVERS I>.CC()'JNT NuMBER B1RTHDATEiAGE 61
11 LONGSTREET DRIVE 2001272485 11/29/97
CARLISLE, PA 17013-0000 1Y'6'/O~ rr6M4 DISCHARGE DATE / / I STAY
18:29 06 11 04 00:00 0
GU~'Il'5 ~Ir[j' 6 1 9 fi"'J'7'!f1!t'~' - 9 8 5 3 HIST~'d'1l'::f'8 0 619
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INSURANCE NUMBER INSURANCE DESCRiPTION INSURANCE RANK (1-8ILL FIRST)
8101 PIP NO FAULT 1
ITEMIZED (DETAIL) BILL
DATE
ITEM#
DESCRIPTION
QTY
AMOUNT
TOTAL CHARGES
*** TOTAL
1,634.32
1,617.98-,
1,617.98- I
16.34- j
16.34-
.00
08/09
2610
NATIONWIDE
TOTAL PAYMENTS
10/26
8285
AR TO BAD DEBT TRANS
TOTAL ADJUSTMENTS
-t4t-a/ 4ft~/ JI
''(J'tyrV04 Bl3'7h/04
u
j""ttbSHUA TRAVERS
1 ACCO~T~"IJ"f~ 72 4 8 5 - 0 1
't'i:DERAL TAX NUMBER #52.0591628
PLEASE KEEP THIS BILL FOR FUTURE REFERENCE
CHARGES MAY BE ADDED TO YOUR ACCOUNT P.S A RESULT OF SERVICES PROVIDED BEFORE DISCHARGE BUT BILLED AT A LATER DATE.
PA-105 (9/02)
-
d~/Ly/LUU8 ~q:~b
/!C:i4!jHJ467
TRAt'lSCARE
PAGE 01/03
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4TRANSCARE
Tn. driving torce In health p;~r&
Fax
Date: CL~3 laC)
To: Uc::~ ,,1, ^10>>-ef
Company: ~ at- Lcu..V
Fad: !(JIO- q~3 -0570
Telephone#:
From: J e r\(\ \ 'c.e..r f.t '
(718) 763-aS88 ext 452>
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Total # pages: (3)
COMMENTS: 10 n ,ryj--
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~'ff SOD [lfYJ m<. a:I!J pa..-y
'Vl/lvtl" .
This fax is intende(l only for the use of the addressee named above and may contain
information that is privileged and confidential. If you are not the Inbonded recipient of this
fax, any dissemination, distribution, or eopying is strictly prohibited. If you receive this fax
in .".or, please immediately rtotify the sender by calling (718) 763~888. Than~ you.
---
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TRANSCARE
PAGE 03/03
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STATEMENT PATE ....CANCe DU~ ~~d8'./ll'ik1
07/02/04 SO!475.oa
SERVICE DATE SHOW AMOUNT $
06110104 PAlD HERE
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~ SERVICE REQUESTED
QUESTIONS CAll 800-794-7936 Ex! 391 9:00AM-5:00PM
PATIENT NAr..1f.:.'
JOSH TAAVER5
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ADDIlESSEE:
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CARROL..L TRAVERS ~
11 LONGSTREET DR
CARLISLE, PA 17013-8111 r ~ .,/
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TRANSCARi: HARFORD COUNTY, INC.
P.O. SA 631802
BALTIMORE, MO 21263-1802
PAGE: 1 of 1
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PLEASE DETA.:H AIID filriilt-.riiiiWR"ENT
$ERVICI:
DATE
06/10/04
06/10/04
06/10/04
CLAIM
DESCRIPTION
AMOUNT
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SC'I' SPIlCIALt'Y CARE 'l'XP
J\.LS MILEAGE
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1150.00
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FROM , PENINSULA REGIONAL MEDICAL CTR
'1'O:tJNIVE:RSITY HOSPITAL . .x.
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TOTAL CllARGEll
2475.00
PAYIolENTS
0.00
BALANCE
247S.00
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AODRE.':;S sERViCe REQUESTED
FOR BIlliNG INQUIRIES CALL: (410) 543-9332
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11 LONGSTREET DRIVE
C/O BRIDGETTE TRAVERS
CARLISLE. PA 17013-8111
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TRAUMA SURGICAL ASSOC
560 RIVERSIDE DRIVE A206
SALISBURY, MD 21801-4704
!)111 !/'"H-lh'AOl/WN!,O(>O()ti8
STATEMENT
l"I..fA5'f Dr.1ACH AND fltTUAN lOP fJOfiTlON WnK YOUR PAYM1:.NT
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Dehnarva Collecions, Inc,
P.O. Box 37
Salisbury. Maryland 21803-003'7
(4- IO)-546-3 742
Fax: C 410)-860-8084
. Date: 2/7/06
To: Lilia J Mauer Esq
Attention:
From: Joanne
~~~ Bridsette Travers (Joshua Traverli) Emerg Serv Assoc 6/11/04
D779456
1 have received notice from my client they will accept settlement
of $450.00 on the above claim
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of pages including the cOYU page.
This is an att.t:mpt to collect a debt and any infoanacion obtained will ~ used for that purpose.
Conhdcntiol Nocico: Watrling Unauthoriud lot<<<<pUoo "fThi& T<:Itphoru.: Communiwioo Co.dd be a violacioo
ofF<dual and Maryland La... The DO<:UIlVl\1;S n... Accompany This T dccopy TWWIlw,,,,, Contain ConIicknci>l
Infonnari"n B.longin& to <he Seo.ckr Which i> L:g:illy Priviltged. The Infonnabon i> [.,.moded Only for the U.. of
th. Individual of Entity Nam<d Abo....lfY au An Not th.lmmoded Recipient, You an: Hon:by Notif.... Tlul .....y
Dud"",,,,, Copying, ~.ioo. or The Taking of Any in Rdionc< on Th< Comonu of This T d.ccopicd
Infotma,ion i5 Strictly PtOhil>ited. If You H.ve Received This T d<eopy in Em:>r. PIus. Immedi>tely NotilY us by
T eltphone '0 An1ng< for Tho Rewm Of <he Original Docummt '0 .....
This Communication is From Delmarva Collections. Inc.. A Debt CollectOr.
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~E~GENCY SEaVICE ASSOC
F.O Bo)<3012
Wilmington, DE 19804
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VISA _MlC_
CARD NO:
EXP. DATE:
P\:J'r all billing questions, .call: 410/546-3742
"ax 10: 52-0936535
AMOONT:
SIGNATURE:
paeient Name: JOSHOA TRAVERS
11 LONGSTREET DRIVE
CARLISLE, PA 17013
STATEMENT DATE: 9/7/2004
AMOUNT DUE: 646,00
In~urance: AUTO ACCIDENT
ACCOONT #: SA657411
PROCEDORE
DATE CODE
DESCRIPTION
DIAGNOSIS
CHARGE
CRlWIT
06/11/04 99291 CRITICAL CARE(lST HO
06/11/04 72050 CERVICAL INTERP.ONLY
06/11/04 72170 PELVIS INTERR.ONLY
06/11/04 73560 KNEE !~TERP.ONLY
06/11/04 73560 KNEE INTERP.ONLY
06/11/04 93042 RHY/CARDIAC MONT.
PLEASE CALL AOTO INSORANCE INFO.
873.40 823,82 E919.9
WALTER D. GIANELLE, M.D.
873.40
973.40
873.40
873.40
673.40
873.40
534.00
23.00
23.00
23.00
23.00
20.00
AMOUNT DUE: 646.00
-. PLEASE FORWARD A COPY OF YOUR INSURANCE CUD (FRONT ANO BACK) IF YOU
A~E REQUESTING WE BILL YOUR INSURANCE.
. THIS BILL IS FOR THE EMERGENCY PHYSICIAN WHO TREATED YOU AT
PENINSULA REGIONAL MED.
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130232!i8931
NA TIONW10E CLAIMS
Nationwide Insurance
11U!>!) 03-17-7006
212
Prepared by Chris Parks of Financial Settlement Services
.
-,
Today's Date:
Name:
Date of Birth:
March 17. 2006
Joshua Travers
November 29. 1996
Male
Age:
*HT
9
PlanA
Guaranteed Lump Sum Benefits:
Guaranteed
Amount:
Cost:
Payable - 11/2912014 (age 18).
$78,393.72
$52.590.05
$52.590.05
$47,409.95
$100,000.00
$78.393.72
$47,409.95
$125,803.67
TOTAL STRUCTURE AMOUNT:
Cash at time of SetUement:
TOTAL PLAN AMOUNT:
The Internal Rate of Return is approximately 4.71% and
the Tax Equivalent Yield is 6.73%. based on a 30% tax bracket.
This proposal is effective through MARCH 23, 2006. 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.
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_ FINANCIAL SETTLEMENT SERVICES
~_ Providing Strucwred Solvtions-
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DATE:
TO:
As of July 2005
Financial Settlemenl Services (FSS) Clients
SUBJECT:
Hartford Ratings
The following is a summary of the current ratings for Hartford Life Insurance Company.
Hartford is a highly rated company by the various rating organizations.
This Hartford case would include a Qualified Assignment to Hartford Comprehensive
Employee Benefit Service Company (Hartford - CEBSCO). Financial Settlemenl
Services will request an Evidence of Guarantee from Hartford Life Insurance Company
and Hartford Life, Inc. (HU). guaranteeing the obligations assigned to Hartford -
CEBSCO. This guarantee is issued with the policy and is not part of the Release and
Qualified Assignment.
Hartford Life Insurance Company ratings are as follows:
Rating Organization Hartford Life (provider and guarantor)
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.
FINANCIAL SETTLEMENT SERV1CES
t}53 MT. HERMON RJ). SVITI::: 101
SALrSBlIRY, MD. 21804
Office: 800-993.9931 x2S
Office: 800-34941BO x19
Cell: 410-430.52B7
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GRAHAM & MAUER, P.C.
By: LisaJ. Mauer, Esquire
ID # 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, PA 19482
(610)933-3333
Attorney for Petitioner
CUMBERLAND COUNTY COURT OF COMMON PLEAS
In re: JOSHUA TRAVERS, a minor
No. OL -;2NY CW.l L~'UL~
ENTRY OF APPEARANCE
Kindly enter the appearance of LISA J. MAUER, ESQUIRE, on behalf of Petitioners,
Bridgette Travers and Carroll Travers, parents and natural guardians of Joshua Travers, a minor, in the
above-captioned matter.
GRAHAM & MAUER, P.C.
By:
Date: y- 5- c Co
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APR 2 8 2006
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GRAHAM & MAUER, P.C.
By: Lisa J. Mauer, Esquire
ill # 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, PA 19482
(610)933-3333
Attorney for Petitioner
CUMBERLAND COUNTY COURT OF COMMON PLEAS
In re: JOSHUA TRAVERS, a minor
No. 0(.,. -~6::(~ CULL ~~
PRELIMINARY DECREE
AND NOW, this ,sf- day of 'f)~ ,2006, it is hereby ORDERED and DECREED that
a hearing on Plaintiffs' Petition for Leave to Compromise Minor's Action will be held on the
I J 'tf...- day of tnq , 2006, at 10:00 tllll..in Courtroom 5 of the Cumberland
County Courthouse, Carlisle, Pennsylvania.
BY THE COURT:
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GRAHAM & MAUER, P.e.
By: Lisa J. Mauer, Esquire
ill # 65426
Suite 22, P.O. Box 987
Valley Forge, PA 19482
(610)933-3333
Attorney for Petitioner
In re: JOSHUA TRAVERS, a minor
CUMBERLAND COUNTY COURT OF COMMON PLEAS
C~;L '[f/L~
No. Qf- - ;;)'6'J.Y
ORDER
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AND NOW, this " day of t\ " '(
,2006, upon consideration of
the foregoing Petition, it is hereby ORDERED that the settlement of this action for One Hundred
Thousand ($100,000,00) Dollars is hereby approve~ counsel fees and expenses are allowed, and
distribution is dictated as follows:
TO: GRAHAM & MAUER, p,e.
For costs
$457.05
TO: GRAHAM & MAUER, P.e.
For counsel fees (25%)
$25,000.00
TO: MEDICAL PROVIDERS
For unpaid medical bills
$1,341.34
TO: DEPARTMENT OF PUBLIC WELFARE
For medical insurance lien
$10,611.56
TO: JOSHUA TRAVERS, a minor
For restricted bank account to be
accessed on 11/29/2014 (age 18)
$10,000.00
TO: Structured settlement (cost)
$52.590,05
Guaranteed lump sum payable
to Joshua Travers on 11/29/2014
$78,393.72
Total (Paid by Nationwide Insurance Co.)
$100,000,00
BY THE COURT:
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