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HomeMy WebLinkAbout06-4968 ROY BISHOP and CHRISTINA CARBAUGH, as Parents and Natural Guardians of BRANDON BISHOP, a Minor, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 0(..- ~9t.! C;r.Jtt'Y~ Petitioners v. DANIEL L. KREHLING, Respondent AND NOW, corne Petitioners, Roy Bishop and Christina Carbaugh, as parents and natural guardians of Brandon Bishop, a minor, and together file this Petition for Approval of Minor's Settlement and aver the following in support thereof: I. Petitioners, Roy Bishop and Christina Carbaugh, are adult individuals, residing at 139 Third Street and 93 Second Street, Apartment B, respectively, in Enola, West Fairview Township, Cumberland County, Pennsylvania 17025. 2. Petitioners are the parents and natural guardians of Brandon Bishop, a minor, who was born on January I, 1997 and who is presently nine (9) years of age. 3. Brandon Bishop was injured on May 17, 2005, when he ran in front ofa moving vehicle, operated by Respondent, Daniel L. Krehling, causing the car to strike the minor pedestrian along Second Street, in East Pennsboro Township, Cumberland County, Pennsylvania. 4. As a consequence of the accident, Brandon Bishop sustained a fractured right femur. 5. On May 17, 2005, Brandon Bishop underwent successful surgery, and had placed into his right femur flexible intramedullary nails for stabilization. He remained hospitalized for three days, until May 20, 2005, for purposes of initiating physical therapy. Prior to discharge, physical therapy felt that the patient was safe to go home with continued physical therapy. He was cleared to go up and down stairs with the use of a walker and was taught the proper use of a wheelchair. A copy of Hershey Medical Center Discharge Summary, dated May 20, 2005, is attached hereto as Exhibit "A". 6. Brandon Bishop progressed with physical therapy, and by December 23, 2005, the intramedullary nails were removed from his right femur. No complications or future medical procedures are necessary. A copy of Hershey Medical Center Operative Note, dated December 23, 2OOS, is attached hereto as Exhibit "B". 7. At the time of the accident, the car that struck the minor pedestrian Brandon Bishop, which was operated by Respondent, Daniel L. Krehling, was insured under a policy of insurance issued to him by Peerless Insurance Company, bearing policy #33PM629780, which policy provided liability coverage in the amount of $100,000.00 for each person, and a combined aggregate in the amount of $300,000.00 for each accident. A copy of the policy Declarations sheet is attached hereto as Exhibit "C". 8. The parties have settled Brandon Bishop's claim for the sum of$25,000.00 (hereinafter referred to as "settlement amount"). 9. The settlement amount will be paid out pursuant to a structured settlement providing for guaranteed monthly payments in the amount of Four Hundred Thirteen Dollars and Sixty-Nine Cents ($413.69), for a Period Certain ofTen (10) years, beginning January 1,2015 through December 1. 2024. A copy of the proposed Settlement Agreement and Release is attached hereto as Exhibit "D". 10. Petitioners understand that the undersigned does not represent either of them and, in fact, the undersigned was retained by Peerless Insurance Company solely for the purpose of facilitating Court approval of the aforesaid settlement on behalf of their minor son, Brandon Bishop, as required by PaRC.P. 2039. II. Peerless Insurance Company, on behalf of its insured and Respondent, Daniel L Krehling, shall be responsible to pay all court costs and legal fees charged by the undersigned in preparing and filing the within Petition and in attending any proceedings required to obtain court approval ofthe minor's settlement. 12. The parties hereto seek approval of the settlement on behalf of Brandon Bishop, a minor, in the amount of$25,000.00, to be paid pursuant to a structured settlement providing for guaranteed monthly payments in the amount of Four Hundred Thirteen Dollars and Sixty-Nine Cents ($413.69), for a Period Certain ofTen (10) years, beginning January 1, 2015 through December 1,2024. A copy of the proposed Settlement Agreement and Release is attached hereto as Exhibit "D". WHEREFORE, Petitioners, Roy Bishop and Christina Carbaugh, as Parents and Natural Guardians of Brandon Bishop, a Minor, respectfully request that this Honorable Court enter an Order approving the settlement and compromise of the personal injury claim on behalf of Brandon Bishop, a minor, in the amount of $25,000.00, undiminished by legal fees, costs and/or expenses. Respectfully Submitted, THOMAS, THOMAS & HAFER. LLP ~ Anthony T. Lucido, Esquire Identification No.: 76583 305 North Front Street P.O. Box 999 Harrisburg, P A 171 08 (717) 441-7057 Date: 7/'1/o~ 421612.1 We, Roy Bishop and Christina Carbaugh, as Parents and Natural Guardians of Brandon Bishop, a Minor, do hereby verify that we are the Petitioners in the above-captioned action and further verify that we have read the foregoing document and that it is true and correct to the best of our knowledge, information and belief. We understand that false statements herein are made subject to the penalties of 18 Pa.C.S. ~ 4904, relating to unsworn falsification to authorities. Date: "'~,~~ I I Roy Bish Parent and Natural Guardian of Brandon Bishop, a Minor Date: "bs./o~ I ' Christina Carbaugh, as Par and atural Guardian of Brandon Bishop, a Minor I, Rick Stains, Jr., a Paralegal for the law fIrm Thomas, Thomas & Hafer, LLP, hereby certify that I have served a true and correct copy of the foregoing document by fIrst-class, U.S. mail, on the following persons, on the 2 ~ay of ~.u<(- , 2006: Roy Bishop 139 Third Street Enola, P A 17025 Christina Carbaugh 93 Second Street, Apt. B Enola, P A 17025 THOMAS, THOMAS & HAFER, LLP By: ~Cl Ri;;:n~~ P'alegal to Anthony T. Lucido fx h\bf-r A PENNS'rATE IS MJIton s.~ Medical Ctmer ., College of MediCine Patient Name: BISHOP, BRANDON T PSUHMC MRN: 0773262 D I s c h a r 9 e Summary Document I Final Document Electronically Signed by: Cilley, Robert E 5/27/20052:35:03 PM DISCHARGE SUMMARY Name: BISHOP, BRANDON T HMC Number: 773262 DOB: 01/01/1997 Date of Admission: 05/17/2005 Date of Discharge: OS/20/2005 ADMISSION DIAGNOSIS: 1. Status post motor vehicle accident. 2. Right femur fracture. DISCHARGE DIAGNOSIS: Same. PROCEDURES: 1. 5/17/05 - flexible 1M rod of rightfemur. BRIEF HOSPITAL COURSE: Brandon Is an B-year-old male who was a pedestrian struck by a car to the right lower extremity who was brought to the Hershey Medical Center as a level 2 pediatric trauma. The patient's primary survey was negative and his secondary survey was significant for a right femur fracture documented clinically and radiographically. The patient's other labs and radiographs including CTs of the head, c-spine, and abdomen were ali within normallimils. The patient was evaluated by the Pediatric Orthopaedic Trauma team and was taken to the OR for the above noted procedure. Postoperatively the patient remained hemodynamicaliy stable. He was advanced to a normal diet and received pain control via oral narcotics. The patient did stay postoperatively until day #3 to work with physical therapy. The patient required use of a wheelchair and teaching on crutches. Prior to discharge, physical therapy fell that the patient was safe to go home with continued physical therapy. He was cleared to ambulate up and down stairs with the use of a walker and was taught on the proper use of a wheelchair. DISCHARGE MEDICATIONS: 1. Tylenol with codeine elixir 5.10 mL every six hours as needed for pain. 2. Senokot available over-the-counter as needed for constipation. DISCHARGE SERVICES: 1. The pallent will be seen by Pinnacle Home Health to provide nursing assistance and physical therapy at home. 2. The patient's physical therapy goals involve evaluation, therapy, and mobility and safety issues to his right lower extremity. 3. The pallent will be receiving a 14" wheelchair, a child's walker from Praxair. DISCHARGE INSTRUCTIONS: 1. Resume regular diet as tolerated. Dat. Printed: 71/812005 7lm. Pri.ted: 4:22 PM PENNSrATE E! Mnton s.~ Medical Center ., College ofMediclne Patient Name: BISHOP, BRANDON T PSUHMCMRN: 0773262 I Discharge Summary Document I Final Document Electronically Signed by: Cilley, Robert E 5/27/2005 2:35:03 PM 2. Nonweightbearlng to right lower extremity. Keep the right lower extremity elevated with heel propped when not ambulating. Observe the toes and lower right extremity for any signs for increased swelling, change in color, or change in sensation or temperature. If present, you should call the orthopaedic resident on call with these symptoms. 3. Keep your right leg dressed In the dressing provided and keep the dressing dry. 4. The patient may sponge bathe, but please keep the right leg dry as noted previously. Call 531-8521 for the pediatric orthopaedic resident on call for fever greater than 101.3, any increasing or severe pain or any changes in the limb sensation or temperature as described above. Followup appointments with Dr. Vanderhave in Orthopaedics. The patient will be given the day and time of the appointment prior to discharge. The patient has been given a certificate for school absence-and for exemption from physical education classes. 507723 Review/Sign: Eric M Pauli, MD Review/Sign: Robert E Cilley, MD Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier, Kerry Fage1man, Brett Engbrecbt Coleen Greecher MS RD CNSD. Janet Shields MSN CRNP CS Hershey 717-531-8342 HbgIYork 717-920-5200 EMF IEEP DD: OS/20/05 DT: OS/23/05 14:38 Date Printed: 7/1812005 lime Printed: 4:22 PM EXA;b:f B PENNSTATE IS Mllton s.~ Medical Center ., College of Medicine Patient Name: Patient Sex: Patient Location: Visit Type: BISHOP, BRANDON T Male HOSe,. Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Infonnation Services, HU24 SOO University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUllMC MRN: 0773262 Date of Birth: 1/1/1997 Vi,it Number: 5871283 Tet. (717) 531-8055 I Operative Not e Document I Final Document Electronically Signed by: Vanderhave, Kelly L 1/11/20062:08:05 PM OPERATIVE REPORT Name: BISHOP, BRANDON T HMC Number: 773262 DOB: 01/01/1997 Date of Service: 12/23/2005 SURGEON: Kelly L. Vanderhave, M.D. PREOP DIAGNOSIS: Retained hardware. right femur. . POSTOP DIAGNOSIS: Retained hardware. right femur. PROCEDURE: Removal of flexible intramedullary nails. right femur. ANESTHESIA: lMA. EBl: Minimal. COMPLICATIONS: None. INDICATIONS FOR THE PROCEDURE: Brandon Is an otherwise healthy 8-year-old male who was struck by a car now 6 months ago. He sustained a closed right femur fracture. He underwent the placing of flexible 1M nails. The nail has become prominent around the knee, and he requests hardware removal. PROCEDURE AND FINDINGS: The patient was taken to the operating room. placed supine on the table. lMA anesthesia was induced without difficulty. IV antibiotics were administered. The right lower extremity was then sterilely prepped and draped In the usual fashion. Previous surgical incisions were used. Attention was first directed medially. The dissection was carried down sharply. The VMO was elevated. and the nail was identified. The nail was removed without difficulty. The wound was irrigated. Subcutaneous tissues were closed with 2-0 Vlcryl sutures. and the skin was closed using 4-0 PDS stitch. In an identical fashion. the lateral incision was used. IT band was spilt. The nail was identified and removed without difficulty. The wound was irrigated. The IT band was reapproxlmated using 2-0 Vlcryl suture. Subcutaneous tissues were closed with 2-0 Vlcryl sutures. and the skin was closed with running 4-0 PDS stitch. Date Pn'nted; 6/7/2006 Time Printed: 10:25 AM PENNSrATE IS MDton s.!fersIJey Medical Center ., College ofMediclne Patient Name: BISHOP, BRANDON T PSUHMC MRN: 0773262 I Operative Not e Document I Final Document Electronically Signed by: Vanderhave, Kelly L 1/11/20062:08:05 PM Sterile dressings were applied. The patient was then awakened and taken to recovery in stable condition. The sponge and instruments counts were correct. No complications. I was present. 60171528 CC: . Hershey Outpatient Surgery Center 650 Cherry Drive Hershey, PA 17033 . Review/Sign: KellyL Vanderhave, MD Assistant Professor, Pediatric Orthopaedic Surgery Penn State Milton S. Hershey Medical Center PO Box 850, Hershey, P A 17033 (717) 531-4653 KLV ffBL DD: 12/23/05 DT: 01/04/06 12:35 Dale Printed: 6/7/2006 llmePri.ted: IO:25AM ~... EKh;b/-i- C. CHANGE COVERAGE ~ Peerless . \?:II Insurance" NcIllba'CIIUbtnf~GIoup Polley Number: 33P M629780 Prior Policy: 33P M629780 Policy Period: 09/12/2004 To: 09/12/2005 12:01 am Standard Time at the Mailing Address of the Named Insured Coverage Is Provided In PEERLESS INSURANCE COMPANY Blllino Tvoe: DIRECT BILL - QUARTERLY Named Insured and Mailing Address: Agent: DANIEL L KREHLlNG ENDERS INSURANCE ASSOCIATES 115 SECOND STREET PO BOX6118 WEST FAIRVIEW PA 17025 . HARRISBURG PA 17112-0118 Agent Code: 3222055 Agent Phone: (717)-652-4902 PERSONAL AUTO POLICY PREMIUM SUMMARY THIS IS NOT A BILL. YOU WILL RECEIVE A SEPARATE BILL FOR THIS lRANSACTlON. Reason for Tranaaction POLICY CHANGE 01 Base Coverage Premium Transaction Effective Date 09/12/2004 Additional Coverage Premium Premium For This Transaction $ - 5 3 .00 Credits and Debits Total Policy Premium VEHICLES COVERED Veh Yr Make Model Vehicle 10 Number Sym Type St Amt 001 1998 GMC SONOMA 1GTCSl440WK507021 08 002 1991 SATN SL1 1G8ZG549XM1427501 02 - BASE COVERAGES AND PREMIUMS Insurance ie provided where a premium entry Is shown for the coverage. LIABILITY COVERAGES Limits of Liability Premium VEH 001 VEH 002 $ $ $ $ 990.00 0.00 -246.00 744.00 ClNew Property Damage Uninsured Motorist Bodily Injury Underlnsured Motorist Bodily Injury First Party Benefits Coverage Added First Party Benefits Medical Expense Work Loss $ 100,000 Each Person and, $ 300,000 Each Accident $ 92.00 $ $ 1 00 ,0 0 0 Each AccIdent $ 131. 00 $ $ 1 5 ,00 0 Each Person and $ 3 0 , 000 Each Accident $ 11.00 $ $ 1 5 , 00 0 Each Person and $ 30,000 Each Accident $ 22.00 $ 84.00 119.00 Bodily Injury 11.00 22.00 FW1eral Expenses Limited Tort Option $ $ $ $ 10,000 5,000 1,000 1,500 Each Person Each Person and Per Month Each Person $ .52.00 $ 46.00 $ 2.00 INCLUDED $ 47.00 $ 46.00 $ 2.00 INCLUDED PA (07/95) 09/1212004 33PM62978001 1308 AGENT COPY PGOM5600 .124892 PPAOPPN ??oo1458 Page 3 Other Than Collision ".iSONAL AUTO POLICY (contin~;~:; BASE COVERAGES AND PREMIUMS Limits of Liability Premium VEH 001 70.00 PHYSICAL DAMAGE COVERAGES VEH 002 VEH Less Deductible of: $ Collision VEH Less Deductible of: $ Towing and Labor Actual Cash Value 001 VEH 002 100 Actual Cash Value 001 VEH 002 500 $ $ 218.00 $ 6.00 Limit per Disablement: Optional Limits Transportaton Expenses VEH 001 $ 50 $ $ VEH 002 30 Per Day and 900 Maximum $ 9.00 CREDITS AND DEBITS Veh Title 001 PASSIVE RESTRAINT DISCOUNT 001 LIMITED TORT OPTION 001 ANTI-THEFT DISCOUNT 002 PASSIVE RESTRAINT DISCOUNT 002 LIMITED TORT OPTION Premium $ -31.00 $ -90.00 $ -11.00 $ -29.00 $ -85.00 Base Premium $ 659.00 $ 331.00 VEHICLE PREMIUM SUMMARY Additional Coverages Credits and Debits $ 0.00 $ -132.00 $ 0.00 $ -114.00 Total Policy Premium DRIVER INFORMATION Veh 001 002 Total Premium $ 527.00 $ 217 .00 $ 744.00 GS = Good Student Discount DT = Driver Training Discount Veh Driver License Number St Op DOB MIF MIS GS DT 001 01 DANIEL L KREHLING 15059671 PA P 06/25/1951 M S N N RATING INFORMATION Veh Class Price pt Use Miles Days St Territory MultI-Car RATING INFORMATION Veh Class Tierl Price Pt Use Miles Days St Territory Multi-Car 001 885221 2D WORK 05 5 PA 007 Y 002 885121 2D PLEASURE 5 PA 007 Y FORMS AND ENDORSEMENTS Your Insurlince Is comprised of the following forms: Veh Form No. Ed. Date Veh Fonn No. 001 PP0303 0486 ALL PP0551 ALL PP0417 1298 ALL PP0338 ALL PPOOO1 0698 ALL PP0151 ALL 91-5PA 1100 ALL PP1301 Ed. Date 0694 1298 0698 1299 Veil Form No. ALL PP0421 001 PP0302 ALL 90-701 Ed. Data 1298 0698 0695 THIS IS NOT A BILL. YOU WILL BE BILLED SEPARATELY. At your request, your account has been placed on a Direct 8111 payment schedule which is based on QUARTERLY Installments. Please do not send payment now. You will be receiving a saparate Invoice statement(s) based on the payment schedule that you selected. Thank you for selecting us to service your Insurance needs! PA (07/96) 0911212004 33PM52978OP1 1308 AGENT COPY PGDM560D J24892 PPAOPPN ??oo1459 Page 4 Form ing a part of (. " I'>' L...... :~JI ...~,' . Policy Number: 33P M629780 Coverage Is Provided In PEERLESS INSURANCE COMPANY Named Insured: Agent: DANIEL L KREHUNG ENDERS INSURANCE ASSOCIATES Agent Code: 3222055 Agent Phone: (717}652-4902 PERSONAL AUTO POLICY (continued) Date Issued: 0811212004 P A (07/96) 09/1212004 33PM62978oo1 1308 AGENT COPY PGOM560D J24892 PPAOPPN 00001460 Page 5 ----------- \ - . Sy\,-\\ it 1) '. SETTLEMENT AGREEMENT AND RELEASE THIS SETTLEMENT AGREEMENT AND RELEASE (the "Settlement Agreement") is made and entered into this /7.:JA- day of ~ ' 20 O~ ' by and between [among]: "CLAIMANTS" ROY BISHOP and CHRISTINE CARBAUGH, Individually and as Parents and Natural Guardians of BRANDON T. BISHOP (Minor) "DEFENDANT" DANIEL KREHLING "INSURER" PEERLESS INSURANCE COMPANY RECITALS A. On or about May 17, 2005; Claimant, Brandon T. Bishop, was injured in an accident occurring at or near Market Street and North Eno1a Road, East Pennsboro, Pennsylvania. Claimants allege that the accident and resulting physical injuries arose out of certain alleged negligent acts or omissions of the Defendant, and have made a claim seeking monetary damages on account of those injuries. B. Insurer is the liability insurer of the Defendant, and as such, would be obligated to pay any claim made or judgment obtained against Defendant which is covered by its policy with Defendant. 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 Defendant and Insurer from 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 Defendant. 1.2 This release and discharge shall also apply to Defendant's 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 Defendant 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. 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, negligence, or otherwise, and which, if known, would materially affect Claimants' decision to enter into this. Settlement Agreement. The Claimants further agree that Claimants 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 Defendant, by whom liability is expressly denied. 1.5 It is understood and agreed that. the Claimants warrant that no Insurer, attorney, employer, judgment creditor or other person has any type of lien or prospective lien upon the cause of action described in Recital A above or upon the proceeds of this settlement; the Claimants further agree to defend, indemnify and hold harmless the parties released herein from any such claims or actions or from any other claims or 427371.1 20f7 i .l. actions brought against them by virtue of any inaccuracies or omissions in any representations made herein by the undersigned. 1.6 Any and all liens or claims arising out of the incident will be the responsibility of and will be paid and discharged out of the settlement proceeds by Claimants or their representatives, assigns, successors in interest and executors. 1. 7 The undersigned further represents that there are no past or future liens or rights of reimbursement by any hospital, ambulance service, or other medical provider, Medicare, Medicaid, insurance company, workers compensation provider, or attorney enforceable against the proceeds of this settlement or against the parties released, or the persons, firms, or corporations making the payment herein. If such a lien or right is asserted, against the proceeds herein or against the parties released or any person, firm, or 'corporation making payment herein, then, in consideration of the payment made to the undersigned, the undersigned covenants to pay and satisfy such asserted lien or right, or to satisfy the same on a compromise basis, and to obtain in any event, a release and discharge of such lien or right, and, in any event, to indemnify and hold harmless the parties released and the persons, firms or corporations making the payment herein, from any costs, expenses, attorney fees, claims, actions, judgments, or settlements resulting from the assertion or enforcement of such lien by any entity having such lien or right. 2.0 PAYMENTS In consideration of the release set forth above, the Insurer, on behalf of the Defendant, agrees to pay to the individua1(s) named below ("Payee(s)") the sums outlined in this Section 2 below: 2.1 Payments due at the time of Settlement as follows: There is no cash payment due at this time. 2.2 Periodic payments to Brandon T. Bishop made according to the schedule asfollows (the "Periodic Payments"): Four Hundred Thirteen Dollars and Sixty-Nine Cents ($413.69), monthly, for a Period Certain ofTen (10) years, beginning January 1, 2015 through December 1, 2024; and, no further payments beyond said date. All sums set forth herein constitute damages on account of physical injuries and sickness, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 2.3 Claimants hereby warrant and represent that Brandon T. Bishop was born on January 1, 1997. Notwithstanding anything to the contrary herein, if the actual date of birth is not as stated above, and if Insurer or Assignee relies or has relied to its detriment 427371.1 30f7 on the accuracy of the above-stated date of birth, then Insurer may adjust the amount and/or timing of remaining Periodic Payments so that no additional cost than that necessary to purchase the Annuity Contract is incurred by the Insurer or Assignee. 3.0 CLAIMANTS' RIGHTS TO PAYMENTS Claimants acknowledge and agree that neither the Periodic Payments nor any rights thereto or interest therein (collectively, "Payment Rights") can be: 3.1 Accelerated, deferred, increased or decreased by the Claimants or any other Payee; or, 3.2 Sold, assigned, pledged, hypothecated or otherwise transferred or encumbered, either directly or indirectly, by such Claimants or any other Payee unless such sale, assignment, pledge, hypothecation or other transfer or encumbrance (any such transaction being hereinafter referred to as a "Transfer") has been approved in advance in a "qualified order" as defined in Section 5891(b)(2) of the Internal Revenue Code of 1986, as amended (a "Qualified Order"), and otherwise complies with applicable state law, including without limitation any and all applicable state structured settlement protection statutes. No Claimants or other Payee shall have the power to affect any Transfer of Payment Rights except as provided in Section 3.2 above, and any other purported Transfer of Payment Rights shall be wholly void. If Payment Rights under this Settlement Agreement become the subject of a Transfer approved in accordance with, Section 3.2 above: (A) the rights of any direct or indirect transferee of such Transfer shall be subject to all terms of this Settlement Agreement and any defense or claim in recoupment arising hereunder; and (B) the transferee shall be liable to the Insurer, Peerless Insurance Company, to any Assignee (as hereinafter defined) and to the Annuity Issuer (as hereinafter defined) for any and all liabilities and costs, including attorneys' fees, arising from compliance by any of such parties with the Qualified Order approving such Transfer or arising from any claim to any of the transferred Payment Rights by any party other than the transferee. Following any such Transfer, any liability of the transferee under this paragraph, under the Qualified Order approving such Transfer or under applicable state law may, at the Insurer, Peerless Insurance Company's option, be credited and set off against any of the transferred Periodic Payments. 4.0 CLAIMANT'S BENEFICIARY Any payments to be made after death of the Payee, pursuant to the terms of this Settlement Agreement, shall be made to such person or entity as shall be designated in writing by Claimants to the Insurer or the Insurer's Assignee. If no person or entity is so 427371.1 4 of? designated by Claimants, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the Estate of the Payee. The Payee shall have the right to submit a request to change the Beneficiary designation. No such designation, nor any revocation thereof, shall be effective unless it is in writing, signed by the Payee, and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer or the Insurer's Assignee before such payments are made. 5.0 CONSENT TO QUALIFIED ASSIGNMENT 5.1 Claimants acknowledge and agree that the Defendant and/or the Insurer may make a "Qualified Assignment", within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, of the Defendant's and/or the Insurer's liability to make the Periodic Payments set forth in Section 2.2 to Liberty Assignment Corporation ("the Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no greater than that of the Defendant and/or the Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 5.2 Any such assignment, if made, shall be accepted by the Claimants without right of rejection and shall completely release and discharge the Defendant and the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimants recognize that, in the event of such an assignment, 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 Defendant and the Insurer shall thereupon become final, irrevocable and absolute. 5.3 Liberty Mutual provides a Certificate of Guarantee on all cases, which guarantees the performance of Liberty Life Assurance Company of Boston, the annuity Issuer. 6.0 RIGHT TO PURCHASE AN ANNUITY The Insurer, through its Assignee, reserves the right to fund the liability to make the Periodic Payments through the purchase of an annuity policy from Liberty Life Assurance Company of Boston. The Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Assignee may have Liberty Life Assurance Company of Boston mail payments directly to the Payee(s). The Claimants shall be responsible for maintaining a current mailing address for Payee( s) with Liberty Life Assurance Company of Boston. 427371.1 5of7 7.0 DISCHARGE OF OBLIGATION The obligation of the 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 2.2 ofthis 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 by them; and that the terms of this Settlement Agreement arc fully understood and voluntarily accepted by Claimants. 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 CONFIDENTIALITY The parties agree that neither they nor their attorneys nor representatives shall reveal to anyone, other than as may be mutually agreed to in writing, any of the terms of this Settlement Agreement or, any of the amounts, numbers or terms and conditions of any sums payable to Payee(s) hereunder. 11.0 GOVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 12.0 ADDITIONAL DOCUMENTS All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 427371.1 60f7 13.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire agreement between the Claimants, the Defendant 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. 14.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution by each of the parties. CLAIMANT ..y~ and as Parent and Natural Guardian of Brandon T. Bishop (Minor) CLAlliAm !ld -~.. Christine Carbaugh, Individually and as Parent and Natural Guardian of Brandon T. Bishop (Minor) DATE: 6 /;~ ~, I ' DATE: sJyjG , , INSURER PEERLESS INSURANCE COMPANY BY: ~~ TITLE: S6...v 'i <1 / a p..Iq I..-y S ') DATE: 7/u f tJfD 427371.1 70f7 t' ~-t \. t l i: ~ ' ~ 7J () iQ t t .~ :; ~ ~ ~~Pr:J ~ "--'- " ~ <> )v "\ () t'-..3 ~~ ~~ ~ c-- ::;j ,', Ml':!.r~ c ' r,,) -'--' (.n ;::3 i . / '1,' i.);~ --,.1 =< (^' ~ en -< ROY BISHOP and CHRISTINA CARBAUGH, as Parents & Natural Guardians of BRANDON BISHOP, A Minor IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. DANIEL L. KREHLING : NO. 2006 - 4968 CIVIL TERM ORDER OF COURT AND NOW, this 7TH day of SEPTEMBER, 2006, a hearing on the attached Petition to Approve a Minor Settlement will be held on MONDAY. OCTOBER 9. 2006, at 3:00 p.m. in Courtroom # 3 ofthe Cumberland County Courthouse, Carlisle, Pa. Byth~'Court,') L~/ Edward E. Guido, J. Roy Bishop Christina Carbaugh Anthony T. Lucido, Esquire Peter Staats :sld f' ~ :7 '.....,-..J ..,' -- "~--~ ROY BISHOP and CHRISTINA CARBAUGH, as Parents and Natural Guardians of BRANDON BISHOP, a Minor, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006-4968 CIVIL TERM Petitioners v. DANIEL L. KREHLING, Respondent AND NOW, this fQ~ day of ~~ , 2006, upon consideration ofthe within Petition for Approval of Minor's Settlement, it is hereby ORDERED and DECREED that said Petition is GRANTED and settlement between Petitioners and Respondents, by and through their insurance company, is APPROVED as follows: (1) No cash payment will be due at this time; (2) The settlement amount of $25,000.00 will be paid out pursuant to a structured settlement providing for guaranteed monthly payments made to Brandon T. Bishop in the amount of Four Hundred Thirteen Dollars and Sixty-Nine Cents ($413.69), for a Period Certain ofTen (10) years, beginning January 1,2015 through December 1, 2024. (3) Peerless Insurance Company has used the $25,000.00 settlement amount to purchase an annuity from Liberty Life Assurance Company for the benefit of minor Brandon Bishop. The purchase date was May 12, 2006 and the guaranteed internal rate of return on the annuitized funds is 5.26 percent, with a total guaranteed benefit of $49,643.00. (4) The Court hereby approves the executed Settlement A signed by Petitioners on May 14,2006. J. >:f":Ci~) s, tt:' .'".J p-~ j' ~ '..J 9- f" 900l -h""'., ...'-'