The URL can be used to link to this page

Home My WebLink About06-3485 LUKE BUHROW, A MINOR, BY AND THR UGH HIS PARENTS AND NATURAL GUARDIANS, RAYMOND BUH OW AND ELIZABETH ANN BUH OW, Plaintiffs vs. IREN WHITTENBERGER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. O~ - 3l./J?S ClULJ-~ CIVIL ACTION - LAW PRAECIPE FOR WRIT OF SUMMONS TO T E PROTHONOTARY: Pleas issue Writ of Summons in the above-captioned action. l Writ of Summons shall be issued and returned to undersigned counsel. Date: IQ (J.- fcY Respectfully submitted, NEALON GOVER & PERRY By 1JufR~ Michael S. Ferguson, Esquire Attorney J.D. No. 83882 2411 North Front Street Harrisburg, PA 17110 717/232-9900 . . CERTIFICATE OF SERVICE AND NOW, this tr day of )uM-- , 2006, I hereby certify that I have serve the foregoing Praecipe for Writ of Summons on the following by depositing a true and c rrect copy of same in the United States mail, postage prepaid, addressed to: Raymond and Elizabeth Buhrow 716 Forge Road Carlisle, PA 17013 1<<;I~ Michael S. erguson, Esquire ~ ~\i. ~ ~ w ~ ~ "1A lrc ~ ~ ~ J ~, c;::; ;~;j:; ,- - , - cD G _.:Aj .," C) ~ ~i t- 0 i F ~n -u~ ~ ::c~~ ~ RI o . - G-> ~ Commonwealth of Pennsylvania County of Cumberland ,- WRIT OF SUMMONS Court of Common Pleas KE BUHROW, A MINOR, BY AND ROUGH HIS PARENTS AND TURAL GUARDIANS, RAYMOND HROW AND ELIZABETH ANN B HROW 71 FORGE ROAD C ISLE, P A 17013 PI . ntiff Vs. I NE WHITTENBERGER 72 FORGE ROAD C RLISLE, P A 17013 De endant No 06-3485 CIVIL TERM In CivilAction-Law To IRENE WHITTENBERGER, You are hereby notified that LUKE BUHROW, A MINOR, BY AND T ROUGH HIS PARENTS AND NATURAL GUARDIANS, RAYMOND B HROW AND ELIZABETH ANN BUHROW, the Plaintiff(s) has I have co enced an action in Civil Action-Law against you which you are required to defend or default judgment may be entered against you. 11ft ~~ (SEAL) (" pr~ JUNE 19,2006 By Deputy At omey: MICHAEL S. FERGUSON, ESQillRE N me: NEALON GOVER & PERRY 2411 NORTH FRONT STREET HARRISBURG, PA 17110 A dress: PLAINTIFF A orney for: Plaintiff T ephone: 717-232-9900 S reme Court ill No. 83882 Plaintiffs NO. 06-3485 LUKE BUHROW, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, RAYMOND BUHROW AND ELIZABETH ANN BUHROW, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs. IRENE WHITTENBERGER, Defendant CIVIL ACTION - LAW PETITION FOR APPROVAL. COMPROMISE. SETTLEMENT AND DISTRIBUTION OF PROCEEDS OF A MINOR'S CLAIM 1. Plaintiff is Luke Buhrow (hereinafter "Plaintiff'), a minor, having been born on February 5,1996 and residing at 716 Forge Road, Carlisle, PA 17013. 2. Raymond and Elizabeth Ann Buhrow (hereinafter "Petitioners") are adult individuals and the parents and natural guardians of the plaintiff who also reside at 716 Forge Road, Carlisle, PA 17013. 3. Defendant, Irene Whittenberger (hereinafter "Defendant"), is an adult individual having an address of 720 Forge Road, Carlisle, PA 17013. 4. On January 9, 2006, Luke Buhrow was injured as a result of an accident that occurred at the home of Irene Whittenberger, 720 Forge Road, Carlisle, Cumberland County, PA. 5. Plaintiff in this case suffered a laceration to his cheek when he was struck by a golf club. "A". . 6. The Plaintiff was subsequently treated by emergency medical personnel at the Carlisle Regional Medical Center. A copy of the relevant medical records from the Carlisle Regional Medical Center are incorporated herein and attached hereto as Exhibit 7. The Plaintiff subsequently treated with Giesswein Plastic Surgery. He was discharged from treatment effective February 2, 2006. A copy of the relevant medical records from Giesswein Plastic Surgery are incorporated herein and attached hereto as Exhibit "B". 8. Defendant was covered by an Allstate Insurance policy that covered the Defendant for the above-captioned matter. The Declarations Page is incorporated herein and attached hereto as Exhibit "C". 9. In order to resolve the claim of the Plaintiff, the Defendant has agreed to pay $20,000.00 for full settlement of the minor Plaintiff's claim against the Defendant. $18,000.00 is to be placed in a Structured Settlement account that will be purchased with an annuity policy from Allstate Life Insurance and $2,000.00 will be asked to be paid immediately to payoff the medical bills that are currently outstanding. Those medical bills are incorporated into the records attached as Exhibits "A" and "B". 1 O. The undersigned counsel has been retained by Allstate Insurance Company for the sole purposes of seeking Court approval of the Settlement Agreement as stated above. 11 . The Petitioners understand their right to obtain counsel for themselves and for the minor Plaintiff, but have elected to proceed pro se. 12. Petitioners understand that the undersigned counsel does not represent any party in regard to this other than the Defendant and Allstate Insurance Company and has agreed to allow the undersigned counsel to proceed accordingly. 13. Any fees generated as a result of the involvement of the undersigned will be paid by Allstate Insurance Company, aside from any amount involved in the settlement, and will not reduce the settlement amount in any way whatsoever. 14. Plaintiff and Petitioners have further agreed that the settlement fund of $18,000.00 shall be paid pursuant to a structured financial settlement established through an annuity purchased through the Allstate Life Insurance Company. If approved, this structured financial settlement will provide for the following payments to the Plaintiff: (i) February 5, 2014 - $12,250.00; and (ii) February 5, 2015 - $13,400.00 providing a total payout of $25,650.00 under the Structured Settlement Agreement. A copy of the Structured Settlement Agreement is incorporated herein and attached hereto as Exhibit "0". 15. The Plaintiff and the Petitioners have agreed that if the Court approves the settlement they will complete the Settlement Agreement and Release. WHEREFORE, Plaintiff and Petitioners believing that the settlement described herein is fair, reasonable and in the best interests of the Plaintiff, respectfully request Respectfully submitted, that this Honorable Court approve the settlement and authorize Petitioners to execute the Settlement Agreement and Release. Date: 7/N I(J~ NEALON GOVER & PERRY By 1Lk~ - Michael S. Ferguson, Esquire Attorney 1.0. No. 83882 2411 North Front Street Harrisburg, PA 17110 (717) 232-9900 , Exhi bit A ,LISLE REGIONAL MED CENT? SPRINT DR' ~LISLE PA 17013 LEPHONE (717) 960-1680 'ATIENT NAME RLISLE PA 17013 ISURED'S NAME ~EATMENT AlJ1HORIZATlON CODES :MARKS ! CMS-1450 85 PAOV\OER REPf!ESENTATlVE X- OCR/ORIGINAL RR O? '?O/OR I CER11FY THE CERTIFltAnoNS ON THE REVERSE APPlY TO THIS BIU AND ARE MADE A PART HEREOF. .".,r~.! ." ~,~ CIWTI_ , '" .....~". Cor.., .. I" II Plo,1I .0.0 / IME ROOM NO. 01/09/2006 18:02 /' \ ADMISSION RECORD 0001048153 .P 'A. J!I_'~~?~2;~~!:~~iNt~ (:: :"; ::: ::::3 PROGRAM A STUDENT -......-,.~., .~.';........... ...:".,t..:~~.:. ~.=....;.. CUMBERLAND G': BUHROW, RAYMOND P lJ" 7 16 FORGE RD ~'CARLISLE PA 17013 US EMERGENCY CONTA(;T NAME STUDENT (717)241-6443 PATIENT EMERGENCY CONTACT PHONE EMEflGENCY ONTACT RELATIONSHIP TO PATIE/IIT WHITTTENBERGER, IRENE (717)243-5410 PRIVA n ,"~o, l' ' O/OJ i: IN '-N'-,,: S" U ,::R;' 'A.,-, N. _n_:__:3,' ""'!_<O.,: I n - -:':""':-, c E o. / ~:o GATRELL, CLOYD B $ c; MPUCATIONS 1A00BIDlTYCIESI <<:IPAL PROCEOURE 40001.0. nuz4I ~~nnlllllwmlm 0001041163 I11U111t111m11 MEDICAL RECORDS COpy m~IIIIIIIHIIIHIEm ~ confuSiOii------- Translator GIJBIIIIf ALoe Intoxication Severity Unrnllable ---,-----..-----om '--..,-..iiiiii':f"----_.- ,-, ----'------------- Emergent mu Non-Emergent U ..- -- .._ __ n. ._ _ .... . --'-~-~i-- -u-k.~---~ ------~ --------- .-------------- -----=t;..:t---------=-- ------- -----15. <:::./ 1--.- - ----- -.--- = ~__=_------u_-_ =~-~5i~~ ~~+---t :.-_:--= _~~_~ !i Sxsx-=~=yal_ :~~~.!~-~-:"i ~~ ~-~=--= ~ - _ camol'describe cough sore ttVOal ear pain abd pain . - N I V dlarrtlea irriiabie DrJri mild moderate severe 1.10 scale __.__ ----timp max > 100.-4 ------.-------------------- -- - ':.... ...,. -:'" ..... U~.- _ --- ____-,,~ -g __ Tyi.;;;I ~ tlme none~-iii~ le~.intake N/V ----.-- - _.....--=----_:,-'----' O'O' __,.,__. . __. depressed -------M-.-.____.~_.M._.___. polydipsia . - --. prurflls lesions ..... App ......, negatlve-- m ... daYC818 Taba _ PacIcs I Day IRi@J ~1J11. Up.to.daie: Y I N m1]..g__=~MP . Pro-MED Maximus ~1'l2llO1 -~-~u.c. R I L Handed Years ETOH: Y I N_ Drii;kSiW~-Oruga: Y-Tfr------- - ~ -...,-- ,- ,,-- T.tMua: unknown . ~_._._~-------------._- G p AS General Pediatric . Page 1 of 2 ~.- } . Carlisle Regional Medical Center r I . E! Laba rwvlewed .nd .... neg.tive X-R.y: CXR: -=[--<:---- ~----------_._- -------------------.- ~_.__._.__.._.._.._,._---~-_.__.__.._._._._-- IVF: NLI ABN .._.~.__._-------_.._--- _._._-_.._-_._._._-......._-_._-----_.~---~-- NL I ABN D1FF -.------------ S --=___ ~.=---_._-_. L_ RapId Slnp: + I- ----.-- RSV: +1- RE-EVAL: TIme: .----....--..------.-.--- -.------...--..-..-..-.-- ImprO'V.d-"-'- S.n:;.--wo;;e-- UA":--- _. Pu'" Ox: % NI- I hypoxia CSF (... proc:eclunt): febrile Illness URI viral syndrome bronch/tla pneumonia pharyngitis otitis media '--menlngltis UTI sepsia -gastroenleritis other: -..-----.-----.----.-...------ Critical Care: 30-74/75-90 191-104/105-120 '---- 121-134/135-184 Minutes .----..---------..---.- Exel. bJll8ble proc:. _..2_____________ - . ~..)' r-----!:--.-i--__ 2. ____..._.______~- ---1~~~_ 3. Discharged to: Home Nursing HolM Family ------...-.-.------ ------_._. ,---_... Follow-up wtth Patient'. Dr. In days. --------.--n-.--- ---- -.- Otherlrmructlona: _ . -- 1:./7 ---- --~ --... - ---- . - -" _--::J - -----.--_______M_._h_.__..._. 4- - ;:--------- -. - -.-- CONSULTATION DISPOSITION DJacuaaed with Dr. Discharge TIme Out: Admit AdmIt: OBS leu ,;cu- floor T.... OR PrHci1pt1ona GIv.n: Follow:Up In omce-------- Tran~f...;------------'-- Old RecordSRevI8w8d Y IN--- _. M..________ h__W_M bVIewect DlWiiacitO-logIat-Y7N'--"-'- ea.. DIW P8il....t I FamIly Y I N Signatures: ....... ~. Pro-MED Maxlmus DCclproWN lIlO1 ___~.,...., L.L.C- proc hec:l [5) MDlDO. Record Camp.... General Pediatric. Page 2 of 2 _.- . ' ------------W-~...A~-===--=---::=--"-.-----,.-.----___,_.....__._'__.____._._'____.___,.....,__..__ '2.,cm . te _ ~~u~~ar~~~ 8eAa~~,~ I, '~c.~:~_:- -> _____________ 4'_ .-.--___..4..~ irregular _ flap __ st~late___.il~IS!~n_______________..________.___ ____ _ -1OfllJil!....bod>'---@-._.._._ ~ .~~___~.~~:~L;~~~~t~~~ .~. _.. ~ lIillllIIL__skin # - _'-----2!.c;>~~ n I____-~-t~p-Ies Dermabond sterl-strJps_______________ . pIe interru tea ___.._~~ng __'!'~tt~~ho!i.!L~ert _________._.___________.__________ _________ ____ ~_ - 0 vic'Y-' silk _____~imP..le~~~~rupted runnjng__.._~!I!!!~ horiz I vert.._______.___________..__________ fascia I muscle I tendo!!.!!... - 0 vicryl__ simple inte~p_tet!_ runnin9__ mattress _._h~riz! vert 4,:...~u__:J:e~1. "~,7":rr~'J~' ~4::~ Y/N Other: l~~~, ~l~:'~:"~~~~ '<<"L1~~".,~.~ ~-_._._._.._----..._-_.__..~......_-._~_.__._---~--_.----'-_."-"~ ---.-.- .--.------. ~~rJ~ ~ ".!i~<,~~..j~.~ - -_._~._-_._------_._--_.._----------_.._.,_.__.._._..-.._-..__._--_._~._-_..__.__.._-_._--_._--~._- em ~ tendon fu~ct~on intact vascular intact sensation Intact __ superficial subcu~neous muscle te"-~~~_._ bone __ linear i,!~ular flap stellate avulsion ~... clea" foreign bod)'__________ __ local digital bJ~_ cc's1% lido 2% lido .5% marcaine w I epi w I bicarb - betadine.---h-ibicien~_" __ saline irrlgatlon--- debrid_~~nt exploratiO""-- skin # _--:Lprol~~~~~.~les___Q_~abond simple interrupted running mattress horiz I vert ____________~~bcutaneous # ...............~_'_9._._...Y.lcryl silk ___________-'__sfmp!~ interrupted .. runnJng____~attress horiz I vert ____..____~scia I '!'uscle I te~~~!__ - 0 v_~_.._._"___ simple Inte_rrup~~ running mattress horiz I vert ._--_..~.~_.._-------------_._.- -.-..--.--.--.----_._M___.____ -------_._--_._---_._~----_. .. steri-strip~_ __.____._____ --.---..H._..H...___._____~.H._._.___..___.____ ~-- Y/N --------.-----.---Other: --,---------------.. ---.-- .-.------.-----.--..------. ~~H ~ ...).~:"~..~':: ,,:'.~~.-~~:: ,,' ~..~/.~~It Y/N Ltl:.j'.:l~ .i: ~(.~tl: "J,~'.~~.i.~r;lr Signatures: Pro-MED Maximus ~Ill:lOO1 -MEO_~LLC. MDlDO Laceration Repair JIIov._ ORDER PROCEDURE FORM . MEdicAL EMERGENCIES i Carlisle rleglonal Medical Center Name:BUHROW, LUKE R Pt#:9329248 Age: 9YRS OOa:02lO5I1996 Sex: M . MR#:0001048153 EOP: GATRELL, CLOYD B. PCP: · NON-STAFF. NO PHYSICIAN- CMP LPM .". ... -- - - Improved 0 Worse 0 Unchanged ImptOved 0 Worse 0 Unchanged Improved 0 Worse 0 Unchanged ImptOved 0 WorM 0 Unchanged Improved 0 Worse 0 Unchanged Improved 0 Worse Cl Unchanged Im~roved 0 Worse 0 Unchanged o KVO Device: OIV Fluid: o Cardiac Monitor: Rate o NIBP Monitor Rhythm: DNGT Insertion #_ Fr. o Gastric Lavage o Central Uno Placement o Endolracheallntuballon o Cardloverslon o Pulse OxImetry o Urfnary Catheter Insertion: #_ Fr. o Oral AJrway Insertion o Oropharyngeal Sucllonlng o CVP Monitoring o CPR (7~ ff'!c // EMERGENCY DEPARTMEN I - ONGOING NURSING ASSESSMENT Carlisle Regional Medical Center Name:SUHROW, LUKE R PI#:9329248 Age:gYRS D06:02l0511996 Sex: M MR#:OOO1048153 . EDP:GATRELL, CLOYD B. PCP: · NON-STAFF, NO PHYSICIAN. , , Dale: 1/9/2006 Airway Clearance, Ineffective -Anxlety -Breathing Pattema, Ineffective Caro~cOu~~,~NS~ Comfort, Alteration In -Other .' ~.~. .. --"'-"~~'~=---"'---:-O;::._'='.-''"--:''"''''~''''~_.2.''''''':__'~'''''_'W~~~P:''''''''~-r-:-:-: Communication Impaired --COPing, Ineffective Fluid Volume, AItel'atlon In Gas Exchange, Impaired _ Hyperthermls (Fever) Infection, Potential Injury, Potential ~edge Deftclt -Mobility Impaired Non-compllance -Other - '.~.-.. Self Care Deftcll --Skin Integrity Impairment -n,OUght Processes, Impaired Thought Processes, Alteration in _TIssue Perfusion, Alteration In -."0.' -_,,,.,,-q--~ ,.- ,-._~~--"'-- - _ ,'-'~~ ,"' Hat Met Met lid Not Met Met lilt Not Met Met Int c Fa REMOVAL C BLEEDING CONTROL C PAIN CONTROl. C ALLEVIATE NN C FEVER CONTROl. C DECREASE ANXIETY C SAFETY IN THE ED C IMMOBIUZATlON I PROPER ALIGNMENT C DECREASE I PREVeNT SWELUNG C MAINTAIN STABLE HOMEOSTASIS C MAINTAIN SKIN I TIssue INTEGRITY C PREVENT FURTHER INJURY C MAINTAIN I IMPROVE CIRCULATION C INFECTION CONTROL C IMPROVEMENT OF BREATHING [J STABILIZE PATIENT IN DISTRESS C meet ENVIRONMENTAL NEEDS [J meet PSYCHOSOCIAl. NEEDS C meet SELF CARE ABILITY NEEDS [J meet EDUCATIONAl. NEEDS C Other lilt: N.. documenllllicn In IlUl1eI no.... other 'cadea' per Hospital Pollc;y. I I v-~V I I ~~.1.'A' "--tAl rL1.t111. f,'" /.~ n ~i-IJ . , L I' IA/1 ~--J1 V IVJ/Fd 117-n1l.. AA /1 . flV I ull#i/.r-J" " ~ ',w- / ( I v v~ . r'J L -........, J n, I A A"Arl ,1 ., , 14 1'1 ~A' r) } ,t !",1 Ii !LJ. ~ -r fLu'l .. '../r 'A ~. (}bLA I-J.. eJ v,j . ' v ~17. VI v ~ I '" { .. . ..1 '1/' 17 ' ! 7 J ~ ~ ;:- . " ,filA. IiIl ,,%11. :, d tAli ~j dr7i 1t/ ~ ~,r.. :b: ("~~ 14- j ~ /h" . JA ; ^ / /1 J) .; ~Dr]/;;J--;l 0 AJ,. / tx AI" ." /I ~ /? J;r;j, ~. ~ ~ Jli <J- '~ J // ......~ rL.... ,.. ~ J/11/1..J ,1. --"L \ -. b4,. , (/ lLiu'(h // Af1 i- -1. fA A A1J11 _PrJ rei' U 111 -; "7"'~A -I lA,lIl /;th l... ~ f71-t~j _ 7 ' ~ D ."., ---.. - / ......~ j '"' o",JVUI _...... r-:fI.. ~ !J . , D &dIn reof: ~b gWlCcStretcCarrled Discharge InstnJctlons given 10 . '. .21<!erllallzed understanding Admit: Room #:_10 Dr. . Ready for Room Time:_ Report called at and given 10 Transf8red to C Transfer Verttl~ Report called at and given to [J Left without treatment cleft Against Medical Advlae Condition at Dlspos~on: Clmproved ~ta~e [J~erlous [JExplred Pain Scale: ..:::et:. Pain LEtIon: ~J/J Patient reports that pain Is: ~~d CUnchanged lfWonse 1'( Disposition Vitals: TVtI. f p -S?l- R~ BP qq Ir:.., 02 ~1) DIsposition Date: I J;1 TIme: la%rNurse~1I1_ / lh,'j , f~ ~. ~ DRey,~ EMERGENCY DEPARTMENl PEDIA TRIC NURSING ASSESSMENT . Carlislerteglonal Medical Center . Pt#: 9329248 Sex: M MR#: 0001048153 PCP:. NON-STAFF, NO PHYSICIAN. Name:BUHROW, LUKE R Age: 9YRS DOB: 02105/1996 EDP: GATRELL, CLOYD B. . Date In: 1/912006 Time: Subjective Notes: Environment: . [J No steps. [J Few steps C Many steps Nutritional status: [J Nannal [] Cachetic C Obese Religious I Cultural preference: C None (speclfy) Beslleam by: (pt I caregiver) CVerbal cWrltten cRetum demo Leamlng Barriers: [] Heavy C Pulsating []NEW BORN All- 0.1 Month OINFANT 1.12 MonlM Language: CCries Often CSmiles OC60S I Gurules OBabbles Bom alTenn:CYes ONo Delivery: CVaginlll OC-SectIon Diet 0 Breast Feed CFonnuJa type: Elimination: C 3 - 8 stools a day Other: Actlvtty: Ufts Head: OVes ONo Sits up: Clwith help C without help Crawls: 0 Yes 0 No Teething: 0 Yes 0 No Observation of InteractIon with caregiver Is o Approprlate ClSee Nursing Assessment CTODDlER All- ,. 2 v..... C Pre-School All- ~.. v..... Language: ClFew WortIs OSentences CI Eas8y Understood DIet CFlnger Foods CRegular Diet OFeeds Self Uses: OBottle CI Cup TeethIng: OYes ONe elimination: 01 - 2 Stoots per day ODlapens CToIlet tralned OWeta bed: C Rarely 0 Oc:casionally ActMty: Waks: 0 Yes CI No OWalka with assistance CWalks Independently ObHrvaUon of Interaction with caregiver Is o Approprlale oSee Nursing Assessment OSCHOOl AGE Age'. 11 v.... CADOlESCENT Aa_12 .1. v.... Re!lChed Puberty: 0 Yes 000 Diet 0 Eats 3 mealalday ClEating disorder: (spedfy) EIlminallon: 0 No problem reported CI Wets bed: ORarety OOccaslonany Social Habits: Smokes 0 Yes C No USes AJcchol: eyes eNe ObMrvlltlon of Interaction with caregiver Is C Appropriate CISee Nursing Aueasment Vital Signs: 18:11 T: 97.8 P: 92 Regular R: 18 BP: 109/068 Uses: CBottle OSpoon CCup eFrequenay Leamlng dlsabUity; eyes Wears Braces OFrequenUy Uses Drugs: C Yes ONo School grade: eyes CINe INITIAL ASSESSMENT FORNI PRIORITY: 4 Non-Urgent Carlisle' Regional Medical Center Pl#: 9329248 Sex: M MR#: 0001048153 Patient BUHROW, LUKE R 02/0511996 AGE: 9YRS GATRELL, CLOYD B. .. NON-STAFF, NO PHYSICIAN. Worker's Camp: Emp. Referred: DOB: EDP: PCP: DATE: 01/09/2006 Presentation TIme: 18:02 Triage Time: 18:11 Arrival Mode: WAlKED Height: . Weight: 69.0 Ibs. 31.4 kgs. LMP: Chief LACERATION-SIMPLE ~""'-~'=Ol~""'''''"'-,"" "~'~''''_~.''o~ .,,- .-., Last Tetanus: unknown Ace By: ----,J~--,.-=--=Yita~"'_~ T: 97.8 T P: 92 Regula~, R: 18 Unlabored BP: 109/068 02: % RA Pain Intensity Scale: 1 /10 Paln Location: Face Brief FATHER STATES THAT CHILD WAS HIT IN THE FACE WITH A GOLF CLUB APPROX 1 INCH Assessment: 'LAC NOTED LEFT CHEEK NIGHT SWEATS WEIGHT LOSS ANOREXIA NO NO NO HEMOPTYSIS FEVER NO NO SAFETY NO Sudden Onset Pre-Hospital Treatment: Pediatric G&D App. for Aoe . NO, Invnunlzalion UTD - NO, Height ft. in., Head elre.. Grade., with Assessment: Past Medical DENIES History: Allergies: NKA Medicines: NONE Nurse Signature: Addlllonal Notes: ~~ --rv w tL \\ .1 I Y , MAJ (2--, ~ (Ylq Rev 05i1S104 Carlisle ReRional Medical Center - E. IRenc\. .oartment 246 Park"r St. Carlisle. P A 17013 -- (717) 245-5500 DISPOSI'f,ION SUMMARY J . Buhrow: Luker 1/9/06 6:23pm 1048153 Patient: Buhrow. Luke 55#: CURRENT Address: City: Current Ph: AQeIDOB: Zip: Medical Record: 1048153 Arrival: 1/9/06 6:23pm Disch: 1/9/06 7:05pm Disposition: "~;-='~'<'."'~~""J:~'I:"'_""":=':-:"I-',,<="':,>,.;;-. MD ED: Cloyd Gatrell. MD Res/PAlNP: Duane Stroup, PA-C Ox #1: Head Inlury. Superficial (Unspecified) ICO-9 #1: 910.8 Ox #2: Laceration, Face (Unspecified Site) ICO-9 #2: 873.40 PMD: PMO Ph: #1 Ox EnQI: HEAOINJ.ESW #1 Ox Span: HEADINJ.SSW ~ #2 Ox EnQI: LACERATS.ESW #2 Ox Span: LACERATS.SSW Follow-up: EMERGENCY DEPARTMENT CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST CARLISLE. PA FlU MD Ph: 717-245-5500 FlU Drr: 4 Oavs Other Instr: ice packs. Tvlenol or Motrin as needed. return to the ER as needed MY SIGNATURE BELOW INDICATES: > I have received and understood the ora/Instructions reQardinQ my current medica/ problem. > I will arranQe follow-up care as instructed above. > I acknowledQ9 receipt of the written instructions. as outlined on this an any previ paQe(s). I will read and review these instructions. ~I.....I ~.. ~".~~.~ . - -l~ ofP.ticm Date ( r ~ ,.",.....:.. ..._.,..~-.~_i~~~:-....\"-,:.;..-A.-.,-~ BUHROW, LUKE R Acct#9329248 MR#0001048153 01109/2006 GATREll. CLOVD 008:02/0511998 009 M CARLISLE RESlcNAL MEDICAL eTR 111111 1I"Imnl mill fI WillI 0000. El Hospitals and other healthcare organizations have always upheld strict privacy and confidentiality policies. However, the United States Government strengthened these laws protecting privacy and confidentiality with the implementation of the Health Insurance Portability and Accountability Act (HIP AA). HIP AA mandates that the hospital may not '." rulc;;lU;1;; iufUlllll11iU.u. peltW.uW~ tv the ~e tel,;t;~ vIAl Mli.lw ~ Lk fnvaay w~tLuu1. thw permission of the patient As a result, a patient has the right to have bis/her health informaiion kept private and secure. In our attempt to comply with the HIP AA regulations, you may choose whether or not to designate anoth~r individual to speak to the Carlisle Regional Medical Center, along with yourself, regarding the details of your account. " Please make a selection below: No, I do not wish to designate another individual to represent me regarding.my account. /. , .,. ;,A es, I wish to designate'the following incllvidual to represent me regarding my account. N~: li'a7h:J~h,f ~.13uj';';:.v Relationship to patient: .~. ""7' -e r i ~ ~ 1'-' 9....cJ~ , Date --. cz~ 246 PJrlcerSI. Carlisle, 1''''' 17013 Ph;717.249.1212 PATIENT'S NAME CONDITIONS OF TREATMENT AND ADMISSION BUHROW, LUKE R 9329248 ATTENDINO PHYSICIAN GATRELL, CLOYD B DATE 1& TIME OF AOMISSION 01/09/2006 18; 02 ACCOUNT NO. CONSENT TO HOSPITAL CARE AND TREATMENT , AM ,"ES'NTlNG MY'af FO. 'MERG'NCY SERV'CE' OR AO..,,,ON TO TH' HOSPITAL ANO I VOLUNTA'IL Y CONSENT TO TH, ..NG;!1J'iP__...O......, CARE. INCLUO,"G "IAGNOSnC TESTS AND MEOlCAL "EA TMENT. BY AVTHO'''EDAGENT, ANPEM"-OYEES-OF <HE HOSPITAL: ANO '" "'",OlCAL STAFF. OR THEIR "'''0",,,. AS MAY IN THEI""''''''SI,,"AL JVDGEMENT SE DEEMED NEC,SSARY OR SENE"ClAL TO MY WELL SElNG. . . .'."~~o:,~;.;~,~.~;,:~cv.",~~ . -'ACKNoWu,DGE AND "-"STANO THAT MANY 01' TIE PHY"CIANS ON THE STAFF 01' TH~ NDllI'lTAL. INCLVDING _ ATTENlRNG PHY"""",S, NAMED ASOVE. AND RA~DlOG~TS. ANESTH'-DG/STS. PATHOLD"",S AND "'ESoENCY PHYS~IANS. A" NOT EM""",ES OR AG""S OF THE NOSATIU. SlIT RATHER AIlE lNOEPENDENT CONTRACTO.S WHO NAVE "EN _.... THE pmVlLEGE OF USING "" 'DllI'lT" FACJunES FD' THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. I VNDERS""", THAT"" "'A'.'''nD. AND TREATMENT THAT' "cav, ON A' .....GENCY .... ~ NOT IN".... AS A SIIBmnmON DR REPlACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RelEASE INFORMATION , HER'BY AIITHOR"E THE HD"'TAL TO DISCLOSE TO 'NSVRARC< CDMPANO'. INCCODlNO WO'KERS COMPENSATIO. CAROERS. OR O_R "\Ino, THAT MAY.. U....E FOR ALL OR PART OF THE HeSPITAL CHARGE'. ALL DR PART OF MY HD'"TAL 'ECDRD' AS MA Y SE NECESSARY 'INCLUOING ANT TREATMENT FD. ",COHDL DR DRVG AOJSE DR DEPE'DERC<,. TO DETERMINE SENem, ENTITLE....NT AND ,"OCE'S PAYMENT ClAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFlCA TlON RELEASE I CERnFY THA T THE INFORMA nON G'VEN BY ME IN AI'PL YING FOR PAYMENT LINOE.R THE TITLE XV"' AND TITLE XIX 01' THE 'OClAL SE"'OTY ACT IS CORRECT. I AV""""'E ANY HOLDER OF "'DlCAL OR OTHER INFORMATION ASOOT ... TO "LEASE TO THE 'DClAL SEcvmTY AOM,"ISTRATION OR'TS '."RM"...... OR CAROERS ANY INFORMA"DN NeeDED FOR THIS OR A RELA"O ME~CA", ClAIM. I REOVEST THAT PAYMENT OF AVTHDRlZEO BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS ANO VALUABLES , UNDERSTAND THAT THE HO'ATAL 'HALL NOT BE WIBLE FDA THE LOSS OR DAMAGE OF ANY "RSONALE"'", OR VALIJASLE, "'01.". JEWaRY. OLASSE'. DEN""'ES. DDeVMENTE. ClOTHING. ETC., UNLESS 'VCH ITEM' ARE DEPosITSD IN ,,'" HOSATAL SA". THE HOS"TAL W'LL NOT SE UAIllE N EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ~BOUT YOUR BILL VNOERST ANO THA T , WILL RECE'VE A ~LL FROM THE HOS"TAL FOR ,"DVlSION OF THE HOSPITAL SERVICES. 'NCLVDlNG STAFF AND EOV'PMENT. ANO OR ANY SOI'PLIE' OR MEDICINES VTlLIlEO. I WILL ACED ",CElVE A ISLL FROM AIff PHYSICIAN WHO PROVIDES "OFE'.DNAL CARE TO .... FOR XAMI'LE. , MAY REcaVE A SEPARATE SM "'OM ONE DR MORE OF THE FDLLO,"NG TYPE' OF I'tlYSIEIAN' WHO RENOER SERVICE' TO ME, MY .TTEND,"G PHYSICIAN OR "RSOHAL PHYSICIAN. EMERGENCY ROOM PHYSlClA'. RADIOLOGIST. ANESTHESIOLOGIST. PATHOlOGIST. OR ANY OTHER PECIALIST. . tSURANCE ASSIGNMENT HERE'" ASSOGN TO AND AVTHO~ZE THE NOS"TAL AND PHYSOClANS INVOLVED IN CARE DV~NO THI' PERIOD 01' OLLNESS DR TREATMENT 'E""NAFTER -"ClAN'",. OR THEIR DlJLY AIl"""'''D ASS'GN' TO TAke ALL N'CESSARY'TEPS. ,"THDVT UM~ATlON'. TO ENSVRE THAT ANY 'VRANcE BE",FlTS OTHER,"SE PAYA"E TO ... OR MY ESTA" ARE PAID DIRECT" TO '"' HO'ATAL OR PHY~ClANS. THIS ASSISNMENT OF SURARC< SENEATS 'NCl.UDE, BOT IS NOT LIMITED TO ISLLlNG INSlJRANCE. ALlNG ""'TlONE. "LING SO~. IN MY NAME OR ON SEHALF OF THE "mAL OR PHYSICIAN,. FlLlNO PROOFs OF CLAIM. "U'G '"OSATE CLA'MS A'D "UNO G~EVANCES ANO ALL OTHER ."LAR PROCEDURES. AS "SE AMENDED FROM TIME TO "ME WITH THE STATE DEPARTMENT OF 'NSlJRANCE. I ALSO AGRee TO PROV'DE A'D SIGN ANY OTHER DOCVMENTE IA T MA Y BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. A TEMENT OF FINANCIAl RESPONSI8Q.ITY NOERSTAND THAT I AM "NANCIALL Y ANO LEIlALL Y RE""NSI"E FOR CHAROES NOT COVERED IN FVLL av ANY THIRD PARTY. I AlRTHER ADREE "SHOVLD, NOT PAY THE "lANCE WlTHI. TH'RTY i3GI DAY' AFTER THE DA" OF DISCHARGE. MY AceoVNT WILL BE CON.DERED DELlNOVENT. , REE TO PAY COST' OF COLLECTION. INCLUDlNO AEASONA"E ATTORNEY" "'E' AND CO'TS. CDtLECT'ON AGENCY FEES AND COST,. AND EREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. ~ . PERSON WHO ,,"OWlNGLY A'O WITH IN"NT TO 'NJIJRE. "''''AVO. OR DECE"'E A'Y INSORANCE COMPA'Y. OR FOLES A STATE"'NT OF CLA'M ITA/NING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. 'i'NCE DIRECTIVE IFOft ADMISSION TO HOSPITAL ONL YI 1M TO BE ""'TTEO TO THE HOSPITAL. I HAVE BEEN GIVEN WRITTEN MATERIALS ASDVT MY ~GHT TO ACCE" OR REFUSE MED<C" TREATMENT.' E SEEN I_MEO OF MY mGHTS TO FORMUlATE ADVANCE DIRECTIVE'. , UNO<RSTANO THAT I AM NOT REQUIRED TO HAVE AN ADVANCE "'VE 'N ORDER TO "CE'VE MEDICAL TREATMENT AT TH' Helll'lTAL. I VNOERsTANt> THAT THE JfOSp~AL ANO MY CAREG,vERS WILL FOLLOW TERMS OF ANY ADVANCE DIRECTIVE THA T I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. AL THE FOLLOWINQ OPTION THAT APPLIES) IVE EXEClITED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COpy OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE: AMOUNT OF TIME. VE NOT EXECUTED AN ADVANCE DIRECTIVE AND 00 NOT WISH TO 00 SO. SH To COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION, rtFY THAT I HAVE READ 10 HAVE BEE~READ) THe ABOVE CONSENTS AND CERTI I cJ MONTH YEAR ATu INIT. (FOLLOW-UP DONE BY INIT. DATE INIT. rlONS AND UNDERSTAND AND AGREE WITH THEM. ~ 1)0018 PRINT NAME OF PERSON ABOVE 0001048153 IHOIMIIIIIIMIMlIIIB ;._ _-: w.,~ c~,. IU: lbl~b':H ('t~l GIESSWEIN PLASTIC SURGERY "'JjjiOOKwOOD A VENUE SUITE 1 CARLISLE) PA, 17013 PHONE: 717-249-2424 FAX: 717-249-4534 ~ Including cover sheet: .l1' Ldlu gvA ;ow pages. MESSAGE: . . The infoltmation, which/allows, is doctor/patient-privileged, and is confidential information intended only/or the viewing and use of the individual recipient named above. lfyou have received this information in error, please immedialely notify us by telephone and return the faxed document.filo u.v at the above addre.,,, via U.S. postal Service. Thank you.. If there are any questions regarding the information you receive, or you do not receive all the pages. please call back as .voon as possible. WARNING: Unauthorized use and or inlerqeptlo" o/,his relephonic communication could be.a violation a/Federal and State Jaw. , 1-'.1 r~~-~~-c~~b ~~:qcH r~UM: TQ:16106917401 P.2 ~. _ LEHIGH VALLEY A II state 165SVALLBY CENTER PARKWAY, SUITS 2 . .BBTHLEHEM PA 18017-2293 'tbu're In !;IOOd IIamb. III,IIIIIIIIII'I'IIIII,IIII~ 111,1.11111,1,111,1111,1,1111111,1 GIESSWEIN PLASTIC SURGERY 5 BROOKWOOD AVlt, STE 1 CARLISLE PA ~1013-9S76 February 06,2006 INSUR.ED: IRENE WHTTTENBERGER DATE OF LOSS: January 09. J006 CLAIM NUMBER: $'133242635 GKM CLAIMANT: LUKE;BUHROW ATTN:MEDICALReCORDS Please forward copies of the medical records for the claimant referenced above. Enclosed is a signed authorization by the claimant allowing for the release of this information. These records should include, but are not limited to, all medical reports and itemized medical Ibills. Please also include records for any prior and/or subsequent injuries. If there is a cost for obtaining these records, it will be paid promptly upon receipt of the invoice. Thank you for your ariticipated assistance and cooperation in this matter. Should you wish to discuss this matter, please call me at the number below, and refer to our claim number. Sincerely, 7(p.tliy 9A.atos. Kathy Matos I 800-995-5028 Ext. 74~ Allstate Insurance Co,npany Enclosure(s) , i CP3 R026 51332426350KM rt~-l~-c~b ~~:~cH r~UM: .TI']:16106917401 ! P.3 PrDJrur :NDtu C81 CONFIDENTIAl J ~ /Sf . Pr()Jru~ NDm '2ll3ll t - CMedical Alla Prasa" '-800-328-2179 rcc-~~-~~~b ~~:~cH r~UM: [ledger] Giesswein Plastic Surger~ PATIENT LED,GER GUARANTOR #: 067i001- 00 PATIENT #:066973-00 ASSIGNMENT :yes-no LAST PAY DT:**/**/** LAST PAY $ : 0 . 00 LST PLN PAY:**I**/** LST PLAN $: . 0 . 00 ~~~~eoLLE-e:'!'t~:-, 0.00 INS$ED #1 Buhrow, Ray 716 Forge Road Carlisle, PA 11013 Buhrow, Ray Buhrow, Luke R 716 ~orge Road Carlisle, PA 17013 EMPLOYER NAME: REF DOCTOR:no No, Pcp PLAN 1 :Allsta~e POLICY #:513324~635 GROUP #: ~LAN 2 FR:**/**/** POLICY #: TO:.*/**/.* GROUP #: ~ BILL .~ ~ CPT/PROCEDURE CHECK #:PLAN 01/12/06 216116 png 99203-New.Patient I First Form Pr~nted for Allstate Last Form Pr~nted for Allstate OFFICE: gps Dx:873.40-0pen Woun~ .02/02/06 21690. png.99213-0ffice Visit - I First Form Pri;nted for Allstate Last ~orm Printed for Allstate OFFICE:: gpSDx:873.40-0pen Wound Of TIJ: 16106917401 INSURED :fJ:2 P.4 PAGE: 1 DATE :02/14/06 D.O.B:02/0S/96 CHART: HOME :717-241-6443 EMRG :717-241-6443 EMPLY: S S #:235-43-3188 CLASS:hoDR:-png FR: TO: RQS. CHARGE Office - Level 3 on 01/16/06 on 02/08/06 Of Pac Allstate Level 3 on 02/03/06 on 02/03/06 Fac Allstate o 113.00 for 113.00 E?nl for 113.00 E?n 113.00 <------ o 70.00 70.00 E?nl 70.00 E?n 70.00 <------ for for c Balance for Buhrow, Luke R Balance for Plan Patient Plan CUR1tENT 9.00 18~.00 091-120 0.00 0.00 031-060 0.00 0.00 06-1-090 0.00 0.00 ~ 0.00 0.00 0.00 183.00 Exhibit B n ~ ~ a _h,',.;;.: ...t, ~;-.; ~.~",'~~"" " '~q~~ ''---'i' ( - . /.---... ". / ~. I' ..- v/ ax ID 25-1857164 (" -r 5WEIN PLASTICSURr}l ~. THE CENTER FOR COSMETIC & RECONSTRUCTIV1:. .jURGERY 5 BrookwoodAvenue, Suite 1 Carlisle, PA 17013 Tel: (717) 249-2424 · Fax: (717) 249-4534 www.choosegps.com . . i '1f1~!iai(E'~JI,1'.~~,s~, 049961 2'( 1..- 2rJ'2 ~{ ~:~,.)Jj'''~$;jf(~IEl~Ci;;: 113.00 :~~ lZl. IOIZl PREVIOU . PAllENT ;...~~~.. ~~1::~tr, 02/05/96 : MS- "C;i!!!fi~ ,. . AIJ.5ted:;~~ 51 :3.3c:~t+j=~f}3~i CH 873.4Q! Co-Pay: 0.0e. .:,,: :'... :,;:,.,.::),~'" :,..~t,~l.'+;~' ,.<.,..~.'.~~,_,....".,.'.'..._,"",:..'..'..:.".:.'.:~.:."''''''':'''''''''.''''''ii'",~~..~~~ , ,,~;-- - - '.-' r-':~:>;:F,. i,"'~"-';:".;:,;k; ~">:~~;:'-:\~'1;~"~;'_/" ~~"r,<.-',>'.. '-::.->.~;;~'" '-L~ \~:"'<."l~';,l;'~'_:"~i':'#i~}-.i~,'~j~;k'~:~'~ ~_><~,~: '", ';"0',';"" '~.' '.~ o Carlisle o Nurse o Camp Hill ~;;;~' , ......... ........ '-"-'''-'0 "-'..). "'tC::I"1 r- r-.:;UI'I; TO: 16106917401 P.5 Consultation Note rg CONflDfNTlAt Patient Name: Luke Buhrow Date: January 142-006,...~..."...,;.~~..~.,. Chief C~mplaint: Laceration, left cheek. BPI: LtJk~- \u .. 1 -~..~ Caucasian male wh~ h..J Il hi~_IJAi'R II 'hi,lti lMl.ek repaiuA ...- t 11."'.2006. This was the resu~.f.lllfii&l'Rt -"1.~I'F"""'~~.friends' ~ouse. Iiis father was told to have the sutures remo~ four to five days. PMH: 1$ completely unremarkable. The patient has always been in good health. i MedicatJons: None. Allergie$: None known. The RO~ and past medical conditions were done. I FH: W~ reviewed. Examin~tion: Nine-year-old Caucasian lllal~ in no acute distress. The vital signs' seem stable. lie seems to be afebrile. The cardiovascular and respiratory systems seem to be intact. ',- _.', ': - "" '_.:'-.....i,.,"~.,~,. ,.~',;_....~,._: _._.,.~'~" -." --:;~' ~.;.~' .'~.,_~':..,.: ..:_": J.,'-:t;~-:..::~. ;:. ".,' ~';'.~;...-.lC_ :",' .-',-.f f.iIia~N~Wift:,~K~~k~$e~ffis';to: h~Veh~aledLlIie';~~tfuHyso!ar~'. J .removed;i~~ sUtJ}.1;es, but replaced them with some steri-strips to give it a little bit more support. ;~~.~~{t~'~,-..<::.. :-: ,.' 1 Plan: I ~ould like to see Luke back in three weeks unless there's problem in which case his (ather knows to call me before. Peter Giesswein, M.D. PO/nar .....,..'.:.?.....C-IUJ~I.c.J.... I .u , , 181 CONflOEN1IAl Luke Buhrow I 02/02/06 S/O: The patiept is ~rl:-8 r_nicel . The steri-strips are off. The scar~"J . .r-rir.hiC and red ~nrl the.~~~f wi ning. I explained this to Luke and his father who wa accompanying; him. There is, howe er, n_inisbptf ~~"tU..fac.ia.L.a.qjmation. The patienr lul.\Ol i~d lip position.. '. _JS..Seel1.~ ='~;":-'=-'_""H"_';'~~."''''';'''''' . P: I described ~car massage; sun rotection and scar care with Luke an~ his father in great detail. I also described the use of Mede ma: I told Mr. Buhrow that he could call me anytime there is a question or prC)blern. PO/nar ...... '.~ .... ........,.:. .. .;..~-. .:- ..-........ .......:.;........ .~~.;.'. Bills Paid for Mederma Cream-$13.00 Photos-$8.00 Plastic 183.00 E/R-l,428.67 E/R doctor-413.00 ~",W',632.~1 5133242635 B18, OIL: 01109/06, Luke Bubrow, Id04 r.;:I:l;#-"...~c,; Carlisle Regional1\-ledical Center- 1 Visit d1LQW06-1eft facial laceration, fatherstates chil~ &1............, _ ..L"'..~.ai<<:-Iub swung by 6y/o girl, neiglUI1Jjr"-s ~w, su~ed, tetanus shot given, told father to wait 20 mins.-Or so to watch for allergic reaction ana wOll!ld understanding, IL.~!1~e.k,_ shown un~e!eye, ice,_. ., ,T"", ',_ ." -, -_.._ ,_,', -"_ c.", ,.. _ ._..... "",~. .,-,_ .~.,~.... "0 ....-,.".. , . ._. ," ,..,-"" '."'.~_ . .'_ .....,.. _~. ,'_,..",. '"0 .......~u.....,.._.....~. . .._, ...........~:~'..~J:I.,~".;.>.:;:li:.'olIC"'......~ packs, Tylenol as needed, return to e/r as needed, arrange flu care Giesswein Plastic Surgery- 2 Visits ~!m6-9 year old who ~ionon hi-In" ~i.,k repaired 1/9/06, result of an accident at his parents friends' house, father told to have "_V<7'~n~~,_L!iI~s, healed uneventfully so far, reg\ij\f,,_ures, repia_llt.m~IIt~S, will see him back in Bmw~ lmless he has a problem 02/02/06-healing~'p~ steri-strips off, sOUJ~ .i~'R~hic and red, a little bit of widening, good lip position, described scar massage, sun protection, use of mederma, call with any problems or questions Exhibit C, r ~ ~ ( LEGAL DES: 720 FORGE RD CARLISLE PA170134324 . ,- Michael S. Ferguson From: Handlovic, Lisa Marie I Sent: Friday, June 02, 2006 12:53 PM To: Michael S. Ferguson Subject: RE: Luke Buhrow Mike: Below is a copy of the Insured's coverage screen confirming limits. YY-Guest Medical coverage limits of$I,OOO per person. XX-Family Liability Coverage limits of $100,000 per incident. The police did not respond to this incident. If you need anything further, please let me know. Thanks. CLMNUM: 5133242635 ACCT CO: 010 ALLSTATE CASUALTY POLNUM: 908128593 EFFDT: 04/22 LOSSDT: 01/09/06 LINE: 70 ORG YEAR: 04 INSD: IRENE WHITTENBERGER ADDR: 720 FORGE RD CITY: CARLISLE ST: PA ZIP: 170134324 MORTGAGEE: ERA MORTGAGE ITS SCRS &/OR ASSIGNS ATIMA ADDR: POBOX 5954 CITY: SPRINGFIELD ST: OH ZIP: 455015954 AGENT NAME: C JEFFREY CONANT AGENT NUM: 0024911 PHONE: 717-258-4554 POLICY TYPE: 09 DELUXE HOMEOWNERS - PRIMARY RESIDENCE TOWN CLASS: OPENABLE: AA 159,377 A9 BB 15,937 B9 CC 111,563 CD 1,000 C9 DD D9 FF 500 XX 100,000 X9 YY 1,000 Y9 NON-OPENABLE: CB 200/1,000 CG 2,000 CJ 1,000 CP 5,000 CR CS 2,500 LD 10,000 MM 200 MN 1,000 RC RD 3 RT 2,500/10,000 SS 1,000 TD 250/1,000 TR 1,000 TS 7,968 VP 1,000 WT 1,000 --D 500 ~ POLICY S-CODES: From: Michael S. Ferguson: sent: Tuesday, May 30, 2006 6:03 PM To: Handlovic, Lisa Marie Subject: Luke Buhrow Lisa: I received signed permission from the parents. I need to obtain a copy of our client's dec page or other proof of coverage and a copy of the police report if you have it. Thanks Michael Ferguson NEALON GOVER & PERRY 2411 N. Front Street Harrisburg, PA 17110 717/232-9900 717/236-9119(fax) 6/12/2006 Exnibit D . (", . settlement Aareement and Release .. This Settlement Agreement and Release (the "Settlement Agreement") is made and entered into this _ day of , 2006, by and between [among): "Claimants" _ Raymond Buhrow and Elizabeth Ann Buhrow as parents and natural guardians of Luke Buhrow, a Minor "Insureds" Irene Whittenberger, Riley Whittenberger and Asia Whittenberger "Insurer" Allstate Insurance Company Recitals A. On or about January 9, 2006, Luke Buhrow was injured in an accident occurring at or near 720 Forge Road, Carlisle, Pennsylvania. Claimants allege that the accident and resulting physical and personal injuries arose out of certain alleged negligent acts or omissions of the Insureds, and have made a claim seeking monetary damages on account of those injuries. B. Insurer is the liability insurer of the Insureds, and as such, would be obligated to pay any claim made or judgment obtained against the Insureds which is covered by its policy with the Insureds. C. The parties desire to enter into this Settlement Agreement in order to provide for certain payments in full settlement and discharge of all claims which have, or might be made, by reason of the incident described in Recital A above, upon the terms and conditions set forth below. Agreement The parties agree as follows: 1.0 Release and Discharge , . 1.1 In consideration of the payments set forth in Section 2, Claimants hereby completely release and forever discharge the Insureds and Insurer from any and all past, present, or future claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of recovery, which the Claimants now have, or which may hereafter accrue or otherwise be acquired, on account of, or may in any way grow out of the incident described in Recital A above, including, without limitation, any and all known or unknown claims for bodily and personal injuries to Claimants, or any future wrongful death claim of Claimants' representatives or heirs, which have resulted or may result from the alleged acts or omissions of the Insureds. 1.2 This release and discharge shall also apply to the Insureds' and Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimants, shall be a fully binding and complete settlement among the Claimants, the Insureds and the Insurer, and their heirs, assigns and successors. 1.4 The Claimants acknowledge and agree that the release and discharge set forth above is a general release of their liability claim against the named Insureds. Claimants expressly waive and assume the risk of any and all claims for damages which exist as of this date, but of which the Claimants do not know or suspect to exist, whether through ignorance, oversight, error, 2 negligence, or otherwise, and which, if known, would materially affect Claimants' decision to enter into this Settlement Agreement. The Claimants further agree that they have accepted payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimants assume the risk that the facts or law may be other than Claimants believe. It is understood and agreed to by the parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Insureds, by whom liability is expressly denied. .t.. .... · 2.0 payments In consideration of the release set forth above, the Insurer on behalf of the Insureds agrees to pay to the individual(s) named below ("Payee(s)") the sums outlined in this Section 2 below: 2.1 Payments due at the time of settlement to the Claimants: The sum of Two Thousand Dollars ($2,000.00) on or before fourteen (14) days from receipt of this fully and properly executed document and approval by the competent Court of local jurisdiction. 2.2 periodic Payments. ~nsurer agrees to make payment to Luke Buhrow "Payee" in the following manner: (i) Lump sum guaranteed payments: On February 5, 2014, guaranteed payment of Twelve Thousand Two Hundred Fifty Dollars ($12,250.00) i On February 5, 2015, guaranteed payment of Thirteen Thousand Four Hundred Dollars ($13,400.00). 3 All sums set forth herein constitute damages on account of personal injuries and sickness, within the meaning of section 104(a) (2) of the Internal Revenue Code of 1986, as amended. lit II'" . 3.0 Payee's Rights to Payments Claimants acknowledge that the Periodic Payments cannot be accelerated, deferred, increased or decreased by the Claimants or any Payee; nor shall the Claimants or any Payee have the right or power to sell, mortgage, encumber, or anticipate the periodic Payments, or any part thereof, by assignment or otherwise. 4.0 Payee's Beneficiary Any payments to be made after the death of Payee, pursuant to the terms of this Settlement Agreement, shall be made to his named beneficiary. If no person or entity is so designated by Payee, or if the person designated is not living at time of the Payee's death, such payments shall be made to the estate of Payee. Payee may request in writing that Assignee change the beneficiary designation under this Agreement. Assignee will do so but will not be liable, however, for any payment made prior to receipt of the request or so soon thereafter that payment could not reasonably be stopped. 5.0 Consent to Qualified Assignment 5.1 Claimants acknowledge and agree that the Insurer will make a "qualified assignment", within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, of the Insurer's liability to make the periodic Payments set forth in Section 2.2 to Allstate Assignment Company("the Assignee"). The Assignee's obligation for payment of the periodic Payments shall be no greater than that of Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 4 - ... C L- '" 5.2 Such assignment shall be accepted by the Claimants without right of rejection and shall completely release and discharge the Insureds and the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimants recognize that the Assignee shall be the sole obligor with respect to the Periodic Payments obligation, and that all other releases with respect to the Periodic Payments obligation that pertain to the liability of the Insurer shall thereupon become final, irrevocable and absolute. 6.0 Right to Purchase an AnnUity The Insurer, itself or through its Assignee, will fund the liability to make the Periodic Payments through the purchase of an annuity policy from Allstate Life Insurance Company. The Insurer or the Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Insurer or the Assignee may have Allstate Life Insurance Company mail payments directly to the payee(s). The Claimants shall be responsible for maintaining a current mailing address for Payee(s) with Allstate Life Insurance Company. 7.0 Discharge of Obligation The obligation of the Insurer and/or Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named in Section 2 of this Settlement Agreement. 8.0 Representation of Comprehension of Document In entering into this Settlement Agreement the Claimants represent that the terms of this Settlement Agreement have been completely read and are fully understood and voluntarily accepted by Claimants. 5 ;"- - 9.0 Warranty of capacity to Execute Agreement ~ ." .. Claimants represent and warrant that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Settlement Agreement, except as otherwise set forth herein; that Claimants have the sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that Claimants have not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Settlement Agreement. 10.0 Governing Law This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of pennsylvania. 11.0 Additional Documents All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 12.0 Entire Agreement and Successors in Interest This Settlement Agreement contains the entire agreement between the Claimants, the Insureds and the Insurer with regard to the matters set forth in it and shall be binding upon and inure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 6 ... . I.J ..) 13.0 This following competent 'Effecti'Veness settlement Agreement shall become effective immediatelY execution by each of the parties and upon approval by a court of local jurisdiction. Claixnant Raymond Buhro~ as parent and natural guardian of Luke BUhro~, a Minor BY:- Date: -~ Clai.1l\a!lt Elizabeth Ann BUhro~ as parent and natural guardian of Luke BuhroW, a Minor BY:_ Date: -.= 'Insurer Allstate Insurance company BY:- Title: ~ Date:- 7 - l IJ -v . CERTIFICATE OF SERVICE AND NOW, this J!I!!f day of Jv~ , 2006, I hereby certify that I have served the foregoing Petition for Approval, Compromise, Settlement and Distribution of Proceeds of a Minor's Claim on the following by depositing a true and correct copy of same in the United States mail, postage prepaid, addressed to: Raymond and Elizabeth Buhrow 716 Forge Road Carlisle, PA 17013 ~~ Michael S. Ferguson, Esquire . . JUL 1 8 2006 f' q . LUKE BUHROW, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, RAYMOND BUHROW AND ELIZABETH ANN BUHROW, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs NO. 06-3485 vs. IRENE WHITTENBERGER, Defendant CIVIL ACTION - LAW ORDER AND NOW, this O)O~ day of ~ , 2006, IT IS HEREBY ORDERED AND DIRECTED that a hearing on the Petition for Approval, Compromise, Settlement and Distribution of Proceeds of a Minor's Claim is hereby set for the /41/ day of flu F , 2006 at 3; 30 o'clock in Courtroom No. ~ in the Cumberland County Courthouse, One Courthouse Square, Carlisle, PA 17013. BY THE COURT: . ilJ J. Distribution: ~ael S. Ferguson, Esquire, 2411 North Front Street, Harrisburg, PA 17110 v'faymond and Iizabeth Ann Buhrow, 716 Forge Road, Carlisle, PA 17013 ?y DlJ O~. il en '11 "H I:.' ',J' :i' :' . . :..~o '"' ~:'01Z ~i' Ii ..J,;_.. LUKE BUHROW, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, RAYMOND BUHROW AND ELIZABETH ANN BUHROW, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs NO. 06-3485 vs. IRENE WHITTENBERGER, Defendant CIVIL ACTION - LAW ORDER AND NOW, this I'r day of r-:Iv'f .- .... , 2006, after a hearing on the Petition for Approval, Compromise, Settlement and Distribution of Proceeds of a Minor's Claim, said Petition is APPROVED. The parents are authorized to execute the structured settlement agreement and release on behalf of their son. Upon payment of $2,000.00 to Raymond and Elizabeth Buhrow on behalf of their son for medical payments only, the Defendant is authorized to file a preacipe to discontinue this action. BY THE COURT: r 1J;l\ J. Distribution: Michael S. Ferguson, Esquire, 2411 North Front Street, Harrisburg, PA 17110 Raymond and Elizabeth Ann Buhrow, 716 Forge Road, Carlisle, PA 17013 Prothonotary 2 '"rjS: rr,rn "?> rr' -. :- iJjt.. F'~; .r:- ~I..~ ..:;;c; ~"C' :S:c."" 2 =<! .::- w ~ ~' ~~ t~~ ~ ~ ~1 ~i : l~ f :;;:g ~ ~ 3loo --l c::: :r: G') m:n :;ryFn ~9 -0 :;::lQ ::: .-' -', 5?FJ ~ om ~ ~