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Home My WebLink About06-5383 THIS IS AN ARBITRATION CASE ASSESSMENT OF IWIfGES tEARItG IS NOT REQUIED JAMES W. ADELMANr ESQUIRE .Mail@morrisadelman.com IDENTIFICATION #02604 MORRIS & ADELMAN, P.C. .PO BOX 30477 Philadelphia, Pennsylvania (215) 568-5621 ATTORNEY FOR PLAINTIFF Donegal Mutual Insurance Company 19103-8477 Donegal Mutual Insurance Company 1195 River Road Marietta PA 18547 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Extreme Construction LLC 305 High St POB 335 Summerdale PA 17093-0335 NO. C>L - S3R3 COMPLAINT CIVIL ACTION NOTICE TO DEFEND C;oi L IStLI7l You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. LAWYER REFERENCE SERVICE Cumberland County Bar Association 2 Liberty Av Carlisle PA 17013 717/249-3166 JWA0910.2 1. Plaintiff is Donegal Mutual Insurance Company. Defendant is Extreme Construction LLC. COUNT I 2. Plaintiff is an insurance company duly authorized to issue -insurance policies under the laws of the State of Pennsylvania. 3. Plaintiff at the request of Defendant and/or Defendant's authorized insurance agent, issued an insurance policy of the kind and type as more fully set forth and attached hereto and marked as Exhibit "A"r naming the Defendant as the insured. A true and correct copy of the insurance policy declarations described above are attached hereto, incorporated herein and marked Exhibit "A". 4. The policy became operative and in full force and effect and continued until the policy expired or was cancelled. 5. All credits to which the insured-Defendant is entitled are set forth on the Statement of Premiums attached heretor incorporated herein and marked Exhibit "A". 6. By virtue of the foregoing, Defendant is indebted to Plaintiff in the sum of $12,339.00. 7. Although Plaintiff has made demand on the aforesaid sum of $12,339.00, Defendant has failed and refused to pay the same or any part thereof. JWA0910.2 WHEREFOREr Plaintiff claims there is now justly due and owing by Defendant(s) the sum of $12,339.00 with interest at 6% from August 17, 2005 and costs on Count I. COUNT II 8. Paragraphs 1 through 7 are incorporated by reference. 9. On or before August 17, 2005, Plaintiff provided insurance services to Defendant at the times, of the kinds, in the quantitiesr and for the premiums set forth in Plaintiff's books of original entry, true and correct copies of which are shown as Exhibit "A". 10. Defendant received and accepted the insurance services shown on Exhibit "A", and benefitted thereby. 11. The insurance lS worth $12,339.00. 12. Defendant received the benefit of the insurance services from Plaintiff and it is unconscionable for Defendant to receive those benefits without making restitution to Plaintiff. 13. It can be inferred from the acts in the light of the surrounding circumstances that Defendant implied it would pay Plaintiff for the insurance services. JWA0910.2 14. Under the circumstances of the case, the ordinary course of dealing and the common understanding of mean, there is shown a mutual intention by Plaintiff and Defendant to sell and pay for these insurance services. 15. All conditions precedent to the present action have occurred or been performed. 16. Defendant is liable to the Plaintiff in the sum of $12,339.00 under the theory of quantum valebant, quantum meruit, quasi contract, implied contract, insurance coverages had and received, and/or unjust enrichment. WHEREFORE, Plaintiff claims there is now justly due and owing by Defendant(s) the sum of $12r339.00 with interest at 6% from August 17, 2005 and costs on Count II. BY: ES W. ADELMAN, E UIRE ~ torneys For Plaintiff Post Office Box 30477 Philadelphia, PA 19103-8477 (215) 568-5621 -3- JWA0910.2 YERIF1C~TION Daniel J. Wagner, CPA t states that he/she is Sr. Vice President & Treasure~f Donegal Mutual Insurance Comnany and that the facts ,set forth in the foregoing CQron1iUlt are true and correct to the best of his! her personal knowledge or information and betief,and that this statement is made subject to the penalties of 18 Pa. C. S.A. 4904 relating to unsworn falsification to authorities. Daniel J. Wagner, Sr. Vice Preside t Dated: August 31, 2006 A "rinn COMMERCIAL INSURANCE APPLICATION 12/10A7/TE2004 ~ APPLICANT INFORMATToti SECTION PRODUCER L'SJ!o.,~l (7~7)761-4600 CARRIER NAlCCOOE: __ I ~~RlTER .; . FAX (717)761-6159 _ J\_ ~,.~_____ h -l:Z21-hS .4 Gunn-Mowery Insurance Group, Ine. ~~D P. O. Box 900 Camp Hill, PA 17001-0900 INDICAn! $~ "TT~HED II EQUIPMENT FLOATER l~~ ....... "" '''''''' ~ PROPERTY ~ INSTALLATlONlSUll.OERS RISK VEHICLE SCHEDULE f\1 GlASSANOSIGN : ELECTRONICDATAPROC . aolLER&MACHINERY , ------------- I ACCOUNTS RECEIVABLEI ~ COMMERCIAL tui .~~,:___,______.L sua ~E: ________ -j VAlUAlllE PAPERS GENERAL LlABlLnY L~l WORKERS COMf'ENSATlON AGENCY CUSTOMER ID , CRlMEIMISCELLANEOUS CRIME llUSlHESS AUTO I~ IJMBREI.LA 00019474 -.. TRAHSPORTATIONI TRUCKERSIMOTORCARRlER STATUS OF SUBMISSION PACKAGE POLICY INFORMATION .J OUQTE L.....J ISSUE POLICY ENTER THIS INfORMATION WHEN COMMON DATES AND TERMS APPlY TO SEVERAL LINES. OR FOR UONOLlNE POLICIES. _~ j BOUNOIGlI'llDaleandlorAUac:llC~I: PROPOSEDEFFDATE i PROPOSEIlEXPDATE ~SIWNGP~.1 PAYMeNT PLAN i AUDIT '-l DATE lIME. I.. I XJ DIRECT Bill ,O%S % ?""'" /' ~ p j 1,..1, "/7 tl: " . . I - r I AGENCY BILL I .e'l APP C INFORMATION NAME IFlnt NaIMd ,......... & 0IIIIr Named ......, Building Excellence, LtC Lr:~~l~~c - /,P u#-?-Jd MAlUNG~DRESS lHCLZJf'+of (01 FInt Named Insurlldl t~6L-7 "'7 . ~-,"-1,j4l.aa-~ :?~. H~~~ ~;~eet iSummerdale, PA 17093 I ,_-T~~-Tr~RA;;~~, RATlOHOS" r=r ~~ORG CR:i:ru IIDNUMBER ---- I ~~.. , 1 ~ARTI':!ERSHIP LJJOlNT~~iW'BAnoN-L1- IHSPE CONTACT ---rr f/.~.,E1Jt.-2L~.J.;l-....:4?/J.. ACCOUN1ING IIECOIlDS CONTACT l~.Eatl;-Z/...,7~~Y-~- \..f.: I PREMI S INFORMAT ON LOC. I BLO' ! STREET,CnY.COUNTY.STATI,ZIl'+t i C/TY~ INTEREST ! YRBUlLTi PARTOCCUPIEll ----,.......---+1305 Hi-9ii" Street- -1-~s(DE HOWHER -l-;:-" ~ ~ 4J~- 00001100001 P.O. Box 335 ~OUTSIDE If,}(1,1, TENANT _ I ~ I_ __ AI ___ _ __ ___1_ ___ J~,!lIIIIerdal~_________!A 17093 "_ '-t- : INSIDE W OWNER I ! I -- OUTStOE H TENANT I 'l-1' -.--------, nh --y~---r--r t-J OUTSIDE I --j TENANT I I Contractor, build 2 commercial homes a year ($200,000) Renovations. drywall, block, roofing, concrete and HVAC is sub-contracted out. Demolition and framing, but all the ~ ~/7'1t:J~ €'~K~ ~~OF~--f-~,~~~~~~~MSRELATINGTO-sexuALA8USEOR- r~~~" - .THS.AF.!I!LICANT-HAVE~SUIlSlOWllES7 ----I-. --4IOLESTAlJON~lSCRIMllII.UJOH.()R.NEGl.tGiKUlIRING'.. - ., lOa""""" O."""'.......,,......I.."""....T.,O.... I I" i 8. DURINGTHELASTTENYEAAS,HASANYAPPlICANTBEENCONVICTEO I i ....- .... .r......."''''''''",'''''''.."........''''''''''''''''''', n_""""""''' 'IJ-------l-T~ OF ANY DEGREE OF THE CRIME OF ARSON? (In RI, lhIJ qyeslion must ba I, .3,....A!ty_E>.\P.Os.uB.e.J:O_F~el.E$.,ElJP.l.O~!\I.iS,.cHEMI~SL__ ~ ~ by II1Y ~ Jot PttIP8llY I_nee. FlIlln 10 disclose II t I I ~Ihe 1.ldsl8nce III an..--. corwk:IiOn ~ a II"lJdemunQl' pIlniJhllble by a : 4.. mY_C6.TAStROet1E,E~.I!QS.uBE1__..._____ I cenr_l{!lI!IOClIl!.YJ!II'..ilI!JPliJ!l~I, +- --,- .LNIY_Ol1:lEB.INliWWtCE.WJItl.ll:tl$.COMl'M1Y.QIlBflNlUlJlIWDm2 ,I ...M:'LUN~IBE.cO.I2ItYJOl.AllOtl.S1 __ 6. ANY POlICY OR COVERAGE DECLtaJ... CANCELLED OR HOM-RENEWEO I .).1,0. AMY 8ANl<RUPTC1ES, TAX OR CREDIT lIEN!AGAINST THE APPLICANT t--I -._.CUlUNG.:rHE,P~.3-,(EARS?NOl.Vl..LlCABUii,IH.MQ- , I ~HE.PA$.T-S-V&ARa? ,". 1_ __ REMARKS P.L,/7I?A.tl/<.f' ~/77~Mf ~ ~n(7~e;x./~ ~I!fJ;Id?6 (},If/C-''6?;!!r\ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION,-OR CONCEALS FOR THE PURPOSE OF MISLEADINGdNFORMATION CONCERNING ANY FACT MATERIAL I ERET OMMITS A FRAUDULENT INSURANCE AC I WHICH IS A CRIME AND SUBJECTS THE PERS TO CRl IHAL D rNY: SUBSTANTIALl CIVIL PENALTIES. NOT APPLICABLE IN CO HI NE OH OK O' ME V I URANCE BENEFITS MAY ALSO BE DENI I APl'UCANT'S I SIGNATURE ACORD 125 (7 P~FRrtf5-0~og:~i3E4~_22699 N 1993 CONTRAG,rORS ~M"'~~' ~ONSE~1For pastor pnsentopeaU-) 1. OOES APPliCANT DRAW PlANS, DESIGNS, OR SPECIFICATIONS FCIR. OTHERS? 2. 00 ~y OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAl? I.NN AU "YES" RESPONSES (For pact or prnant operallonll 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 6. DOES APPLICANT LEASE eQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? %OFWORK 'I'UU. 'PAJIT. ~~"...,,$!~; 1l1!!ltUMF.:___ . YES NO PRODUCTs/COMPLETED OPERATIONS PROOUCT$ ANNUAL GROSS SALES I "OF UNIT$ ~I!\ ~CTED INTENDED USE PRINCIPAL COMPONENTS ,. f:~ -- ! . '- . ---.. -- --t .. . . -'. - .~~~-.-~='~-=J=~_____,_____L_. ,1f:1C~~ Rl!Sf'ONSES l~pastor p~oroperallon) YES NO .J. XPI.NN ALL "YES" RESPONSES (Flll' a!.'X..p'!!! Dr l!!!!!!!!.P-rDduct !!LllJ!!!!tlonl YES NO .1. PQ~_~':'~lCA!:iT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? .I 6. PRODUCTS RECAU.ED. DISCONTINUED. CHANGED? ~ , ~,fORE1GN PRODUCTS SOLD, DISTRIBUTED, useD AS COMPONENTS? .I / 7. PRODUCTS OF OTHERS SOLD OR RE.PACKAGED UNDER '/ 3. RESEARCH ~D DEVELOPMENT CONDUCTED OR NEW APPLICANT LABEL? ,/ PRODUCTS PlANNED? / " 8. PRODUCTS UNDER LABEL OF OTHERS? ~ - -- "/ A VENDORS COVERAGE REQUIRED? :7. _4:~UARANTEES, WARRANTIES.. HOLD HARMLESS AGREEMENTS? ~PI30DUCTS RElATED TO AIRCRAFT/SPACE INDUSTRY? ./ 10. DOES AtN NAMED INSURED SELL TO OTHER NAMED INSUREDS? PLEASE ATTACH UTERATURE, BROCHURES, lABELS. WARNINGS. Ere ADDITIONAL INTEREST' ::I:R i '/"K.lA I E RECIPIENT I I ACORD 4" for namAA INTEREST LIWIK;_ __ NAME AND ADDRESS 1...MF...iBS.m<UL--. I I ~ E --'T."-......- " '-, _ _1 ADDmOHALIHSURED :noN: BUILDING: - -i ~PAYEE . I !-Y!~,- I P.9AT; __ , MORTGAGEE 1-:!!;P..Y.!..€Q ~UM.QEB: ~ UENHOlDER . OTWER 'u' j EMPLOYEE AS LESSOR I . DOES THE BUSINESSES' PROMOTIONAL LITERA TURf MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? . El!lP\.AI"'Al.L:YU' USl'ON$e$,(&l:all~lOf.JQII~,Qpq~ 1. Am MEDICAl FACILITIES PROVIDED OR MEDICAl. PROFESSIONAlS EMPLOYED DR CONTRACTED? ..... ,-.---- --------- _2._~~~~yB..E..IQ RAD10ACTIV~g.EAR MATER!&..$? 3. DOIHAVE PAST. PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING. DISCHARGING. APPlYING. DISPOSING. OR TRANSPORTING OF HAZARDOUS MATERIAL? ._(e.Q,J![ldfiU.lI.....~!lJ.,JII.~U"'nks._e!~ 4. Am OPERATIONS SOLD, ACQUIRED. OR DISCONTINUED IN LAST 5 YEARS? .~5=.MCHINER~..P.8_E.QUleMEtf~~BB.EW"~D_tO_QMB.Sl ,6..ANY W,A. TERCIW:.l:..P.OCKS,.8..0ArS_OW~eD~I:l.IRECtOB.LEASED. .7..ANY_P.A~I~G_MC1LLT.I.eS_O.WIllECWENleO, 8. IS A,EEE,.CHARGEDE.ORfARKINGL _9..RECBElI TION_F.~c.ILlrlES.P-ROy.IDEOl 10,IS_THERE.A,SWJMMING,eOOL.ON.THE..fREMIS.Ea.? J .1._SeORIlNG..oR,SOClAl..EYENIS,SeDNSORED. REMARK$(o) C(!Ct4v,,;:> ..,f'b4 CtJ,4tJCl{ ~,/;;A m ~ 1OO!1.AIN.AU..:'t'ell:RUP.ONSU.IF.ll.u"J11ltor./ll'''flt~) . AAY STRU T RAt. ALTERATIONS CONTEMPlATED? . ~MQ!.JI!9Y~O'-URE..QQNTEMM.H.D? 14. HAS APPLICANT SEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? 1 ..QO"y.Q.I,Jj,.e&e~.Mf1.QYE..e.SJ.o_O.B...E.BQM9THE~.f!..O~? 16, IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? fz...Mf_PAY..cARE.F~Ctl.JIl.ES_OP..EMT.EQ.QB.CON:r.BQU.J;:O . HAVE AloN CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE YEARS? 19. IS THERE A FORMAl, WRITTEN SAFETY AND SeCURITY POLICY IN EFFECT? 4Pc~ ~ ~cP~~ aG.-t.f( ACORD 1260S (1197) ATTAC~fl&dCANJ'JNFOIiMArION SECTION O~ 02:06 PM B3E4B_22699 ACO~Q.. COMMERCIAL GENERAL LIABILITY SECTION PROOUcER L _,~E!.t): (717)761-4600 APPUCANT ence, LLC " FAX (717) 761-6159 =1 Gunn-Mowery Insurance Group, Inc. ~~~~~~~~ P.O. Box 900 EFJl'EiilVi ~l EXP~N"D?€~ Camp Hi 11, PA 17001-0900 '.' '. - - - DATE 12/17/2004 :~~~-~- ~-_ _. _ J.~CODE.:.. . 00019474 COVERAGES FOR COMPANY USE ONLY AUOIT x , COMMERCIAL G'EHERAL UAIIIl.I7Y GENERAL AGGREGATE $ 2,000,000 PREMIUMS ---- ,or 1 ClAIMS MADE m OCCURReNCE PRODUCTS & COMPLETED OPEAATIONS AGGREGATE $ 2,000,000 PREMISESIOPERATlONS i OWNER'S & CONTRAClOR'S PROTECTIVE PERSONAL & ADVamSING INJURY $ 1,000,000 1 EACH OCCURRENCE $ 1,000,000 PRODUCTS -- DEDUCllBLES !!~~!~ono~l._____-L- 0_ ,.iQ.,OOO --- 1 P!pPERTY DAMAGE $ MEDICAl.. EXPENSE ~ one P-!.ll $ 5,000 OTHER - j R PER J BODILY INJURY S Cl.N'" EMI'I.OYEE BENE1'ITS $ 1.___ 0 _ h ____,L-_ PER TOTAl. 0CClIUlEHCE OTHER COVERAGES, RE$TIlICllONS ANl)/\)R 'EHOORSEMENTSIFor lllnlcllnon-ownec auto eowoages 11tlIc:b the Bu"..... Auto SedIoII. ACORI) 127) SCHEDULE OF HAZARDS '~t CLASS PREMIUM RATE PREIoI1UM Cl..ASSIFlCAllON COOE .., BASIS nRR PRatIOP$ PRODUC'T\l PREWOPS PRODUCTS - -.... . . --. -- "--"'---'~-- - tf' '-'5;; 000 (J p) I I '/Y,j ;J -.----r---- 0,_____-----.- 1 ~ ~..r.. S'q o~ r' . . --.. .. ... ~.- .,. -- - t.t_6.:r -- .. I , . I 3SQ-.OO(J~ r\ -. .. --./..-- '-- -,--, ...... I / I -" ,.J-. .-._- ----.... . - -, , ! - -- ... -.-.----- -- - : I I - +..--., -~- .- - --- - .. - ,,----- I I , ,--, - t-- ---.-----. --- I ; ---.- --------- -' ,- 1----.. - ,. t-- . -- ,- .. I ! ._.- --.--'--- --~ .. - RAnHG AND PREMUM BASIS IP) PAYROll.. PER $l,OOOIPAY Ie) TOTAl. COST. PER Sl,DOOICOST IU} UNIT. PER UNIT IS} GROSS SAlES 0 PeR $l.000fSAlES 11.) AREA. PER I.OOOISQ FT 1M} ADMISSIONS. PER 1.OOOIADt.I (T) OTHER UMITS 1.. eRoros~D, REteoACTlVf,Ot. tE: 2"ENIlJY. OA "(EJ~r.O_UNIt!lIEBijUP_TED_C~1 s... ' ,C, .\1 3. HAS ANY PRODUCT, WORK, ACCIOENT, OR L TION BEEN EXCLUDED. UNINSURED OR SELF-INSURED _,EROM.NlY_~'OUS..CQV.ERAGE? 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? 1..DEOUC.TI8.LE.P'I;f:tCLAIM:._S ~~NUMaEltO.EEMaOy.E,ES: YES NO .3..IiUMBER.OF_EMaOYEES.COYE8EO.eY.EMP-LOY..EE.8ENEFJIS..etANS:__ _4~BE.tROhC.TlY.E..OAle' REMARKS REMAAKS ACORD 126-8 (1197) PLEASE.COMP.J.EIEREV.E;IlSE SIDE Vll~I~UU602:06PMB3E4B_22699 @ACORD CORPORATION 1993 I DATE 12/17/2004 ACORI). PROPERTY SECTION " . ROOUCER~, (717) 761-4600 APPLICANT . 1A.IC.)19.,E!II:. _ ....__ -,------, -. - (F1lWt .' FAX (717)761-6159 =1 Gunn-Mowery Insurance Group, Inc. P. O. Box 900 Camp Hill, PA 17001-0900 Building Excellence. lLC :ooE: AGENCY PREMISES INFORMATION SUBJECT OF INSURANCE Personal Property" SUB~D~: . _ _ EFfECTIVE DA~ l!XPlRATION DA~ '.)c: DIRECT BIlL -=PU/~- ///7~,.AGeNCY8Au. USE ONLY &0 ~"ENT PWI /~4? AUDIT PREMISE"; 00OO1BU1Ul1NG.; OOool,STREETAODRESS:30S H1gh Street P.O. Box 33S ~.uro, <fOO~JXllNS ~ ~-r"TIONj s~ie;, ; LOSS i =~: DEOlJCT~O __~s~ CON~ TO APPlY I I I ~ " . I , , I - . - .. T' t I "1' ... i I I . . t .AOIl1T101IAL INFORMATION . ~ INCOMElEXTRA ~E TYPE OF IlU$1NUS ORlllNAR'f PAYROU.. POWERIHEAT EX!' PERIOD NON MI'G . _EXCL INCL S OED; UFG to DAYS I!LEC MEDIA MINING 110 DAYS DAYSlS ! MO PElWD $ BUSINESS INCOME WIO EXTRA EXPENSE . . exTRA EXPENSE .. . '. . . , . . T : TUITlOH FEES ~ PREM POWER STUDENTS I I . POWEll -... OTHER EO ! SERVnNC , DEPENO PROP WATER _ 'foCOlN -, CONT LOC REC LOC _ "'COINS s ; ORD OR LAW DAYS;S u.rr; .--: MAX PeRIOD , DAYS: I COMM (DESCR BELOW) _ j MFGLOC . LOR LOC (llESC BELOW) EXTRA ' ,EXPENSE _ DAVS PERIOD REST LIMIT L058 PAV NAME AND ADDRESSlUI FOR OFF PREM POWER OR DEPEND PROP - ADDfTlOIlAl. COVERAGES. OI'TIOHS, RESTlUCTIONS, ENDORSEMENTS AND RATING INFORMATIOH ...,----% _...--'fo _'" _% OTMER OCCUPANCIES . psrl '8UlLT TOTALAREA ,r~.J ~F 7: CONSTRUCTION TYPE Frame 8Ult.DINO IMPROVEMENTS ~NG, YR: in" ...- ROOFING, VA: /9"7 OTHER; RIGHT EllPOSUIUi & DISTANCE ~/'1'?G" BURGLAR ALARM TYPE , . ~ANCE~'TAT. FIRE DlSTRlCTICODENlIMBER I <J:f/Fr If "" ~/?'J/l1~L(J/J'd. 8LDGCOOI!. TAXCODE . ROOFTYPE GRADE . ..)(,PLUUIING,YR: /J1'1'6 -. _ --_. ,-- ----,-- ~ -- --- -- - ---,. --.---..- X HEATING. YR: ..z 00 I WIND eLASS HEATING BOlLER ON PREM/$E$' . VES . ~11YE :r/VS: _ ; CTt(~ IF YU..IS INSURANCE P~D ELSEWHERE? YES LEFT EXPOSURE & DISTANCE ' REAR EXPOSURE & DISTANCE - 7s=r-t, ~#7/e /t:l?~, 4;(,-nc;: ~ ./ CI!R1'IFICATE' I EXPIRATION DATE" exTENT GRADE I PROT CL '. ~ . us;;.,. l..s NO NO CENTRAL STATION . . .. __~ __WITHKEY.8. IGUARDSIWATCHMEN' ; Cl.OCJOIOURLY IIURGLAR AlAIUIINSTAU.EJ) AHD lIElMCEIl BY PREMISES FIRE PROTECTION (Sprlnk..... StI....plpea, COa/Ch....lcaI S~I % SPRNK FIRE ALARM MANUFACTURER r--: CENTRAL STATION I ' . _.. ..,..", ADOITIONAL INTEJIl!8TS , NAME NfD ADDRESS . tvIDENCE ; . CERTIF- ICAn; POUCY . .RANK:. --! NAME AND ADDRESS IHTERE8T I LOSll I PAVEE MORT- - - GAGEE _EVIDENCE CERTlF. .. lCATE POlICV RANK: _ INTEREST LOSS PAVEE MORT. GAGEE VALUE REPORTING INFORMATION RliPORTlHGFORM:.PROYlDEAVERAGEYALUESf.QR P.AST .12 MONTHS SUBJECT OF.IN5URANCE I -. I PREUISESI BUILDING AHY OTHER LOCA- TION DECLARED .AT INCEP.TlON ANY OTKER L0CA- TION ACCll.MED AFTER IHCEI'TlON PREMISES NOT OWNED OR ACQUIRED LIMIT ---I .__ ___1-- .. -+--____.......J.__. ...__ ACORD 140 1111" ATTO'f!~~o-gr~Br'~Sjf3E4B_22699 o ACORD CORPORAllOIl ,... / ./ ~DI~~ ~~~~~CE~ P.O, BOX 335 f SUMMEROALE, PA 17093 I PAVroTHE IJ.m ~ $ I OROEROF ~ I IJbO/:).co ! fcuy %0(1 Mn.d % DOLLARS l?J E:=- 1 ".W ~ c.-rP - 5:0 ! ... ayRq1nt 00~ \.0c. - bOO MEMO~cIJ ~_~ w I: ~ 31 ~ 3? 2 3~:O .0801:11. 5 ?,;-'o'~Ci9 ~r:'32 0108033457 DATE~ 107 dAb ~\'l€ \(1 iOS o CC. p 01/24/200502:06 PM B3E4B_22699 A, ,,1'0\ 'nn COMMERCIALJNSURANCE APPLICATION U/1DA.7/J'E2004 ~ APPLICANT INFOR ATTo'l( SECTION PROOUCER L(~.!i~~:. (717p61:4600 CARRIER L~CODE: 1 UNDERWRITE. R "" , FAX (717)761-6159 ..1'\_ ~,.~ :;:-~_____ ~t:l71-?4S.~_._--- Gunn-Mowery Insurance Group, Inc. ~~ P. O. Box 900 Camp Hill, PA 17001-0900 'co;e-;--- i SUB CODE: AGENCv CUSTOMER ID -------- -------~ INDICATE SECTIONS ATTACHED EQUIPMENT FLOATER ",,"PROPERTY ,-- H lNSTALLATIONlBUILOeRSRISK 1'1 GLASSAHOSIGN ~i ELECTRONICDATAPROC -- , ACCOUNTS RECEIVABLE! .:1 COMMERCIAL i VALUABlE PAPERS GENEAAL LIABILITY - -- 1 CRlIoIEIMISceu.AHEOUS CRIME 8USINESS AUTO I TIWlSPORTATIONI I TRUCKERSIMOTORCARRlER PACKAGE POLICY INFORMATION L~! GARAGE AND DEALERS [~ veHICLE SCHEDULE 1- ,BOILER & MACHINERY t--; !~-l WORKERS COMPENSATION CJ UM8REl.LA ENTER THIS INfORMATION WHEN COMMON OATES AND TERMS APPlY TO SevEAAL LINES. OR fOR UONOLINE POLlCIES. PROPOSED-;FFDATE I PROPOS';~DATE G~~PLAN _l=-' PAYMEHTPLANL~_ i . - LxJ DIRECT 81LL ; ~ % -;;- / t? Po . . . . I - ! AGENCY 81LL I .el LlP!.~~l~.:..2c - /.p U4/-7-~' 9_ MAlUNGADORES$lNCLlJ""" (of Flr5t tblllld In5urllll) l PHON!! :z ,..., _ ~.,,., "'.L~" 7" 305 High Street ..wc..Ilo...bU~ ~.L,~~-=~-7-0' ; P.O. Box 335 jSummerdale, PA 17093 ~~T;~-TJ~~ [..J~~~S-U,~~9'6RG cR=ruIIDNUMBER --- IW~' . 1 ~ARTN~~_!~,L_1..I9INTVENT\J~~~BAnorLL1__ ---'- tNSPE CONTACT lrHON:Cl.,~:-2L;2.:-;2'.J02 ",\.""~....z ACCOUNTING RECORDS CONTACT [~.ExtL2../-?~~~~~- \.J': I PREMISES INFORMAT ON LOC' l aLD, ~ STREET,ClTY,COUNTY.STATE,ZIf'+4 _11_ClTYUMlTS I INTEREST -ll YRBUlLTt- PARTOCCUPlEO ____ .'--1 .......-130.sHigh Str8"ei- =GS1DE H OWNER A ~.... ~ ..~ OOOOl!OOOOllp.o. Box 335 iiJ OUTSIDE lX~ TENANT & I AI" voo - . - _~_I- ....__ ~~l!Imler9al.~_________ ,___!A !7093 -R:' -+ I - 1 B-!,___ I INSIDE W OWNER I I I ; - OUTSIDE nl I TENANT I I 1 r I i -~r -- 'J::.q=.:-i I OF Contractor, build 2 commercial homes a year ($200,000) Renovations, drywall, block, roofing, concrete and HVAC is sub-contracted out. Demolition and framing, 4.- J!!&./TleJ{) €' IJ .He-. but all the , J ' ) F~~~~~~~OF-AiiOTHER E"'"iYOROOES-------i:Y.~~~~~~OR~~MS RELATING ro-SexUAl ABuSE OR ---tm~1 NQ. _ .THE.APJ!U(;ANl:.HAVE.ANY-SUBSlOlARlES? '-'- -~_-WI.ESf"'llON,ALI.EGA11ONS,.!lSCRlMlHAllON-ORNEGL.IGEN.ulIRllllG1. I ' - ., ISA "........A. W='" D"^'>DU'\U 'O',,",DAT"'",? I I vr i 8. DURING THE lAST TEN YEARS. HAS ANY APPLICANT 8EEN CONVICTED 'i ,,,"- " .r.""""lC!>, .,. ,,",,,,_,-,,0.__,,,,",,, "-' '."'''''.1'''''_ T I ~ OF ANY DEGREE OF nn: CRIME OF ARSON? (In R~ IhI$ queslion _I b. I. ,.;l",.MY.EXP.OSU,~.:to.F.~Gl.E.S.,ElSE'lO~,~S,.cHf~$L_. ~ Ihe.~ by...., appIicalll lot j)I'llpIW\y ~~.!!.!... .!~sdose 11 t I ~I .....tenc8 .. an InOII conviction is. ......... ".,.,,,cr pu. ..,,1lJle by. . : 4._ ANY.CATASTROP-HE,ex.e.o.&.UBil___ I .entence q,\!I! to one Y'-!l!'..!!LiI!@!so!!!!!!!!!I. +- ."__ .5._NIY.OrnER lNSU\WtCE.W/II:IJl:tIS.(d),Ml'1.ll!ly.oasElHG..5UIIMIIJ:ED1__! I AH'LUll.cCBl'lECIElliIBE.CODE.YJPJ.AIIQt1.$1__ 6. ANYPOlICYORCOVEAACEDECLlNEO"CANCELLEOORNOM-RENEWED I ~ ANY8ANKRUPTCIES, TAXORCREOrrllE~AGAINSTTHEAPPUCANT I...L' ..-..CURING:rH6.P~IOR.3.YE-'RS?NO'J:.AP"UCABl.Ei,lfoj.f.'O-----_. . ~-lIUHE.PAST.5-Y&ARS.?.. --.J_ .- REMARKS p..t.o-rl/J.,(,/<'f ~.7"77"'..v.s ." ~':Y2drJ~~ ..J&I;d/6 (},vC"~' ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAJM CONTAINING ANY MATERIALLY FALSE INFORMATION'rOR CONCEALS FOR THE PURPOSE OF MISLEADINGJNFORMATION CONCERNING ANY FACT MATERIAL ERET OMMITS A FRAUDULENT INSURANCE AC I WHICH IS A CRIME AND SUBJECTS THE PERS TO CRt INAL 0 fNY: SUBSTANTIALl CIVIL PENALTIES. NOT APPLICABLE IN CO HI NE OH OK O' ME V I URANCE BENEFITS MAY ALSO BE DEN I , APPUCAH'l"S I SIGNATURE ACORD 125 (7 p~rRftfto27otmI3E4~_22699 . PRIOR CARRIER INFORMATION UNE I C"~GORY ! ' -, ~R~~~ _,__ .- I I f POLICY NUMBER I~; f ,,00;-;;";;- _l~LJ~ 1':1 l~l I: L i-I 1":1 i~EI 1":1 I - - -- I ~~~~ --,-- - EFF-EXPOA~ I 1 ----- G .....' -- - ,--.' -.-- - i I E t GENERAL AGGREGATE , . ~ 'PR6DUCTS-COMPOP i C R I ~AQGREG~TE. - - - - -~--- - I I ~ ~ I t PERSONAl & AOV INJ - - I ! I M L EACH OCCURRENCE E I t.. - - --- I I ~ A ~ I FIRE lWoIAGE - 1 ~ '~r MEDI~~E I I I L LIT I I I I 1 ~ St-BODllY ~~NCe ! I -- , I Y I ~N~~ ..AG2~GATE i , I - 1, , i II PROPERlY OCCURRENCi I ...____1 __" ---t- _. - ----~ -- --- -- - -1" _._- ---- - I DAMAGE AGGREGATE I ,,- ~ '~~N~SING-;;l-;'IT -~----_.-.-- . I ! =-+- ----i I i . t ~!F..'.~TlON FACJOR_ i I ,- , i TOTAl PREMIUM , i I t ~RRER I i 1-- I . I r;-lICY NUMBER -1 I ~ L , ~L/CY TYPE I .- T ~ I Ef.F-EXP.DATE I ~ I I - R ~ ~ CC?1olB!~E1? ~.!!:I~ \.!~ --- ......-- 0 B ~ ~ eoOlL y ~ PERSON L ~ . ~~:I~~_._~_ACClO~ ___ ~ J + I I -- ' E PR9l'~~ DAMAGE ,_ .__ I I --- - l.uqP.'Fl~J19~~'L T -- --I- I J , i I TOTAl PREI.IIUM I , r~~-' ---.- \ , i ~--_. I i - ,------' PQldl<Y !i\L~_ ' --. p I t 1= I R POLICY TYPE __L -, ~_. '... --,-- --.-.,-,. I 0 EFF-EXP DATE p E .. -T--- "-- ' I ---J R I tBU1LDlNG AMT -f i - I _. T 1- , ;;;-;';;-~MT ~ I I I Y .- ~_. - ....,--"''''''- ---, ,-----L I Lt.AQPfF.~t!Q.l'tF~C.!9!L ~,__ I -+-- ~--,_._,--- I TOTAL PREMIUM I I ! f,c~~-- ----1_.. J --- t---. I i I E--'---r--.- - , r:Q!.!j:;Y..!!\I,~p'~!!-===+-- J -- -----L-----" ! ~_"m_ ___ T , I I !;f.f.:~W_>.Ie_~ I ..- i i I -- -- llM1J: ---. - T' I i i MOPlf~tlO!iF.~ClO'lL. Tnn.t 1>I:!>=U1llll I I LOSS ENTER All ClAIMS OR lOSSES (REGARDLESS OF FAULT ANO WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS IXJ.frKdRE I I S~~ACHSD_ "'" "".""", '''' .. -. ... +" DATE OF DATE AMOUNT AMOUNT CLAIM ,. OCC~~NCE l~E_ __ ,~PE/DESCRlPnON,OF OCCURRENCE~~~LAIM OFct.AIM PAID RESERVED STATUS - 1-- t I i-- ~0P.liII. -- _ _, h__ __J,__ _. Cl.Cl__ - ,...Dl!U_ .' " ,~, REMARKS NOTE: FJCeUTY REQUIRES A FIVE YeAR LOSS tlSTORY NOTICE OF INSlJlWICE INFORMAl1ON PRACTICES PERSONAl INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT. MAY BE COLLECTED FROM PERSONS OTHER THAN YOU. SUCH INFORMATION AS WELL AS OTHER PERSONAl AND PRIVILEGED INFORMATION COLLECTEO BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAlINFORMA TION IN OUR FILES AND CAN REQUEST CORRECTION I '2f.!!'!'1INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR P~CTlCES REGARDING SUCH INFORMATION IS AVAILABLE UPON ACORD 125 (7198) 01/24/200502:06 PM B3E4B_22699 ACORD@ WORKERS COMPENSATION APPLICATION DATE 12/17/2004 PROOUCI!R L~._H!:!,~;(Z17LZ 61- 4600 FAX (717)761-6159 COMPANY ~tf2.&t&e AP~ BufTding NAME ~UNG 305 High Street ADD~$ P.O. Box 335 ~='"I' Summerdale, PA 17093 UHDERWRITER LLC 4~~ij Gunn-Mowery Insurance Group, Inc. P. O. Box 900 Camp Hill, PA 17001-0900 CODE: _,.._ _____ SUSCODE: AGENCY CUSTOMER ID 00019474 STATUS OF SUBMISSION I QUOTE ! I ISSue POLICY , X BqUNO (Give date endl~ attach copy) J ASSIGNED RISK (AI1ach ACORD 133) CORPORATION SUBCHAPTER.S'CORP X UM/TED CORP OTHER: ID NUMBER: OTHER RATING BUREAU lD OR STATE EMPLOYER ~G1STRA11OH NUMBER BIWNG/AUDIT INFORMATION I B1~G PLAN PAYMENT PLAN FCY BILL ANNUAl. DIRECT BILL SEMI-...NNUAl OlJARTERL Y ~DIT )(j OTH,ER: ~ ...T EXPIRATION ~.&yJ./I::(.. SEMI.ANNU...L % DOWN: QUARTERlY U MONTHLY o OTHER: LOCATIONS tI . STIIEE1'"ClT'fL ~1!m:-..~!~~ ZIP CODE ; 00001 305 High Street P.O. Box 335 Summerdale PA 17093 -r I , - ICY INF RMA ION , _,~~FF~~=-J PART 1 . WORKERS ART ...... COMP~NSAnOH (SIa..., l!.-~~I,Q.YER'S, UAIIIUlY nknown L. 100,000 EACHACCIOEHT L, __ __,500 I 000 !?J!lP-$HQLK;YLlMIT _ ____ _-.1~__ 100,000 DISEASE E10l 0 ~D PI..AHISAFETY GROUP I ADDITIONAl COMPANY INFORMATlOH I PROPOSED. F.)lD '.....1; t NORMAl. ANNIVERSARY RATING DATE I PARTICIPATING NON-PARTICIPA.TING PART:J - OTHER STATES INS OElltJCl18LES AMOUHT/% OTHER COVERAGES RelRO PLAN MEDICAL INDEMNITY U.S.l. & H. VOLUNTARY COMP FOREIG MAN"'GED CARE OPTION V I I ICOM-L' ST~~ L~~ --=-~_ CODE I P~l CATEGORIES, ~ CLASSlRCAl10NS PA_L~ ~52_-t--k4A~'f'- - L .1_u - - --t---- ...,L_ ;-J- - -++-- I I . \ . .L. .L__ ....l-.......1... SPECIFY AODITIONAL COVERAGESlENDOR$EMEHTS , EMPLOYEES I FUll I PART I -+='lME-f-1lME . I I ~1i '''-L1,______tOO I ! --++t----- .-t-+L - I I ! ES1lMATED ANNUAL REMUNERAOON RATE ESTIMATED ANNUAl P~r.tlJM J.oTAL EACIOR-tJ..AClQREDJ!RE"'UM. ' I S .uMIJS OEDllCllBLE $ .'------- I S I S. EXP..ERIEN.CE.JAODIflCATJON LOss.CONST. LGNED.BfSKS $.____ I -+' Is. I is ISCOUIII1 EXP.ENSE-CONSTANI ACORD 130 (7198) PLEASE.CtlM.P..L.E'[E REVERSE SIDE U1/;l4/2005 02:06 PM B3E4B_22699 << INCIEXC CLASS CODE R!MUNERAnoN ~ ~~ :~O'/fl2 I I ~ , -1- PRIOR'CARRIER INFORMATIONILOSS HISTORY PROVIDE lNFORMAllON FOR THE PAST S YEARS AND USE THE REMARKS SEC1ION FOR LOSS DETAILS ~tt. ./.....-.!! ~ I I LOSS RUN ATTACHED - y~-1 - . -- ---.- CARflIER & POUCY NUMBER - --- ~!'~~~l!!' .- --~ .- .~~ AMOUNT PAID --.- --~~ I CO: - - ___ ,_~~'It.- --.._----- l-f9: - - -~ CO: ,_ _ __,_ -- ,- -+:>..~ - CO~___ --~/I: l-:~;- .- ,.. NAT RE F USINESS/DESCRlPTJON OF OPERATIO S GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS. OPERATIONS AND PRODUCTS: MANUFACTURING- RAW MATF,BIt<L~... PROCESSE~,r.ROoucr~ EQUIPMENT. CONTRACTOR- TYPE OF WORK. SUB-CONTRACTS. MERCANTILE-MERCHANDISE, CUSTOMERS. DELIVERIES. SERVICE-TYPE, LOCATION. F~REAGE, AHI-.S. MACn,NERY, SU8-CONTRACTS. . W'YAl$b.:Y.p:m~$j,$. ~.~I'~e!.~~~~RLE1ASEA 2. OOJHAVE PAST. PRESENT OR OtSCONTINUED STORING, TREATING, DISCHARGING. APPL . DISPOSING. OR TRANSPORTING , . Qf.~~BP.Q.~Mi'.nBIA!.:1-",a.J".!1~!!I!...~ ....~.Jlm.~,_~J _;l.-^ID:.W.O~,el:Bf.QRMEQJ.INPj;,6G.!!O.V!!!;LQR , ~jj.F., _4'n~.IjDYOR.j( p-r;l3F..o.~Q..QN,M8<?{S~V~~I,$" . _(;K~U.BIQ.G!i:9YJ;:!B:YATI;.87 , ,~, !S~a~I{LE~GAGeo.JN,~,Y...O.D.:!.E!Um.Of. _ S1t!r;:SS'/ ~ 9. ~_SUK9NI~T9B$_V.seo..t"t.~S._Q.!Yf..'llo_ .E...W-QRltSl.!,~Otfl:MC_. t1 _ 2. ~_W..QRK.SV~R\.VlJllOJ)~cfBJJEIC!!I~SJ) .8.JS lI,wBlT1Et.tSAEE:tY.P.RO.GIW.1.lli,9P.fAA.TJQN _1I,Nff_GBO,up...:nW"SF!O.B.Tj.~I'lO)(JDEJ)1 , ,a. ANY eMPI.OYEE.S.UNDERJ6_0R.ove~,6Q....YEABSOE.A E? .11. AN"t..seASO.N6L,e!!oleI.Oxa:s? 12.J5T1:ieRe.ANY_~OLUNT.iER,08 OOHATED.l.ABOBL- -'3.,ANY_EMP.LOYEes_WIlKP.l:I.~SICAL,tWi . u. OOEMP.LOYEeS.lRI.\YEL,OUJ', OF....S.TATEL-- LAIN ALL "YES" RES~ 16. ARE PHYSICALS REQUlI'lED AFTER OFF~MPlOYMENT ARE MADE? 17. AN'( OTHER ltI~ce WITH THIS INSl.!R&B? 111..1W'f PRIOR COVERAGE DEClINEOI ""'T ~PPL""'BL "J!N Me CANCEI..I.E~(LaIl..3.ye81S1?__c'Y_ """__'" ,__ ~1iMPj.QYi5l!;s,~N$.ffiQY.1Qfm _,-lSJ]jJi~A !,Ml9.B.JmBC~N~;.w.ID:l.AID'_O_TI:ll;Il.!Mi!t:!~S.V.Il$1PJA!r!J_ _ lcP'!U.Q1.ll~~S.J.Q...O.B.ERQt,(QJH!'R!;Mao.YEB.S U,.QQ,ANYJ:.Mp.LOYEeSJ~B!<Q9M!~AN.II.YJ..tORl5,AJ_HQMe? ,-MlY..WJ.'~_QJliIMKB!.!P.!.C.y...w....IlJ:IJI:i.ItlWtT !;OHTACT.lHE06MA:nc:lN .J4't/ &D UI ;:; 17 ... ~~~.::J:J- APPlICABlE IN TENNESSEE: IT IS A CRIME TO KNOWI L Y PROVIDE FALSE. INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS COM- ANY PERSON WHO KNOWINGLY AND WITH INTENT TO OR STATEMENT OF ClAIM CONTAINING ANY MATERIALl CERNING ANY FACT MATERIAL THERETO. 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Box 302 Marietta, Pennsylvania 17547-0302 (717) 426-1931 www.donegalgroup.com March 9,2006 Extreme Construction, LLC 305 High Street P.. O. Box 335 Summerdale, PA 17093 RE: Account No.: AB 1006453 Balance Due: $12,339.00 Dear Policyholder: Our records indicate there is an outstanding balance due of $12,339.00 on the above- referenced account, which has resulted from activity on an expired/canceled policy. We have sent several invoices to you and received no response. Prompt payment would be appreciated. If you believe this billing is in error or you have any questions, please don't hesitate to contact Janis Kennedy at 717-426-3529, extension 7535. Please forward your payment of $12,339.00 prior to March 22, 2006.. Thank you in advance for your cooperation. Sincerely, DONEGAL MUTUAL INSURANCE COMPANY Vanier J. Wagner Daniel J.. Wagner, CPA Senior Vice President & Treasurer JUL-20-05 WED 11:44 AM FAX NO. p, 02 1)0 ge nsurllnce P.O. Box 900 Camp Hill. PA 17001.0900 5681 " ..:::.... .~\' t)::...,'r,: ~~N.~ r..~;:.":d:~.i:' ~NUrl'lb8r:;b.-'Ji~': i Donega utua P.O. Box 302 Marletta, P^ 17547-0302 All~: Tom Fish L , . workers Compensation Cl il5sifications 001) Amend Change from to PA. Loc #00001: GS2 Estimated Annual Remuneration 65,000 195,000 COllll1ents Applicant Information Named Insureds 001) Am~nd Nl to Extreme Construction, First Named Insured, Limited Corporation Change FEIN " to : 20~3'12238S '0' ......"..._ . . .0.. ..., ..............-:..... ,. ....".M."'.......l......._.~...A."..... .........."".., .,...'M:"Y'L........&lp."'_..r'.............M.... '1' 'j~.I"'~ ,. ..... ,",,' "'0 ." '" ,,'., .....:..., ' '.: .......,.. "t "".'ti">"j~ ,'" ')...., ",.. ~.., "'J..i~' a~ljur.M'ce t(~~~'i .., ~Jm~r~tt,~.l:'~~~~{~~~ttif,/.. ;',;~, '~~~n:~~il..~ri~/U~~~.:.~~~~.!;.t~J;wrJk:~. ~~ ~~ ' ~.~e.g~G.l;' 'f~.I,"i' ~~....!-~~~:-...w! ~:.. ~.! t ~ . ~ . :: ::'.:-. ..:":~:...:..~.::...:~!..:_.--.:~~.~~..':~ .~~~~..\~~~r~D:~\~..1~r::.s..t:'J:.;.~~~~~~t:~~l._.-::11t ::':., .. _ . rllllr.V IoIrr.n~ ,,"gq7\ . A,,",,'11t1. 1SO'l7 07/21/200503:03 PM 6864E_16383 DONEGAL COMPANIES MARIETTA, PENNSYLVANIA 17547-0302 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY COVERAGE IS PROVIDED BY DONEGAL MUTUAL INSURANCE COMPANY INFORMATION PAGE - STANDARD WCOO0001A Amended Polley Effective: 01/1712005 POLICY NUMBER WC 8012n4 00 CARRIER CODE 15636 1. NAMED INSURED AND MAILING ADDRESS Extreme Construction. LLC 305 High Street PO Box 335 Summerdale PA 17093 AGENT NAME AND ADDRESS GUNN - MOWERY LLC POBox 900 Camp Hill PA 17001 OTHER WORKPLACES NOT SHOWN ABOVE: SEE LOCATION ADDRESS FEIN# 203122385 RISKID.# AGENT NUMBER 0005681 00 PHONE NUMBER (717) 761-4600 2. POLICY PERIOD FROM01/ 17/2005 T001/17/2006 12:01 A..M. STANDARD TIME AT THE NAMED INSURED'S MAILING ADDRESS SHOWN. FORM OF NAMED INSURED'S BUSINESS: LLC SUPERSEDES ANY PREVIOUS POLICY BEARING THE SAME NUMBER AND POLICY PERIOD 3. A. Workers Compensation Insurance: Part One of the polley applies to the Workers Compensation law of the States listed here: PA B. Employers liability Insurance: Part Two of the policy applies to work In each State listed In item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $100 rOO 0 Bodily Injury by Disease $100 rOO 0 Bodily Injury by Disease $ 500 rOO 0 each accident each employee polley limit C. Other States Insurance: Part Three of the polley applies to the States, if any, listed here: D. See attached schedule for list of endorsements forming a part of this polley. 4. The premium for this pOlicy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium adjustment shall be made annually.. Classification Description Code No. Premium Basis Total Estimated Remuneration 195,000 Rate Per Estimated $100 of Term Remuneration Premium 14.42 $28.119 Carpentry 652 0063 PREMIUM OISCOUNT -$2,535 MINIMUM PREMIUM: $1,580 STATE: PA EXPENSE CONSTANT: TERRORISM PREMIUM CHARGE: 0938. EMPLOYER ASSESSMENT (0.0236 ): TOTAL ESTIMATED POLICY PREMIUM: DEPOSIT PREMIUM: PREMIUM CHANGE THIS ENDORSEMENT: $140 $76 $609 $26,411 $26,411 $17 , 150 HOME OFFICE COpy Workers Compensation POLICY NUMBER: WC 8012n4 DONEGAL COMPANIES MARIETTA, PENNSYLVANIA 17547-0302 00 EXTENSION OF INFORMATION PAGE STATE PA LOC.l LOCATION ADDRESS 305 High St Summerdale PA 17093 FORMS AND ENDORSEMENTS CONTAINED IN THIS POLICY CMOF 612 (7-04) WC OOOOOOA (4-92) WC 000419 (01-01) WC 370109 (1-05) WC 370405 (8-96) WC 370406 (1-05) WC 370601 (4-84) WC 370602 (4-84) WC 370603A (8-95) PA Construction Classification Premium Credit Application Workers Comp. and Employers Liab. Ins. Policy Premium Due Date Endorsement Workers Compensation And Employers Liability Ins Pennsylvania Merit Rating Plan Endt. PA - Terrorism Risk Insurance Act Endorsement Special Pennsylvania Endt-Insp. of Manuals Pennsylvania Notice PA Act 86 1986 Endt - NonRen Notice of Premium Change THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EFFECTIVE DATE OF CHANGE 01/17/2005 EFFECTIVE FOR THE FOLLOWING REASON(S): Policy Amended LOC 1 Class 652 - Change of Payroll{s) Form WC 370406 Changed for Loc 1 DONEGAL MUTUAL INSURANCE COMPANY WORKERS COMPENSATION AUDIT INVOICE LU-182 3/91 The estimated premium on the policy is hereby adjusted in accord with the audit for the period indicated. POLICY PERIOD FROM 01/17/05 TO 08/17/05 CANC. DATE UNITS PREMIUM DESCRIPTION CODE EFFECTIVE RATE PAYROLL EARNED ASSUMED CARPENTRY 652 14.42 $113,295. $16,337.00 EXPENSE CONSTANT 0900 81. 00 PREMIUM DISCOUNT 0063 -1,245.00 TERRORISM 9740 .04 45.00 EMPLOYER ASSESSMENT 0938 .0236 359.00 EARNED PREMIUM $15r577. LESS DEPOSIT PREMIUM $26,411. TOTAL BALANCE DUE: 00 INSURED D COMPANY $ $10,834. Additional Premiums due Company are payable upon receipt of this premium adjustment endorsement. Return Premiums due Insured are payable provided the Estimated Deposit Premiums are paid in full. This premium adjustment is for the policy period indicated and forms a part of Policy Number WC 8012774 00 issued to: EXTREME CONSTRUCT I ON, LLC Adj. computed at Marietta, PA Date 01/09/06 Agent GUNN-MOWERY LLC (AUTHORIZED REPRESENTATIVE) JUL-20-05 WED 11:~4 AM FAK NO, P. 01 o ge Insurance P.O. Box 900 Cump Hill, PA 17001-0900 5GB! _.._.... .... .._........... ....h........... .. ..... ....._.. __. ........ _......____....._..__.___.__... ...__.__. "':. . .~~....,....,.~I."....I''!;J. ':"'r1'1"'::.;~"1',.: ATT.N: TOIll Fish (I. L A~p'icant Informatio~ Named Insureds 001) AlINmd (han~ frDll\ to Extreme Construction, First Na~cd Insured, limited corporation Na.1ed Insured Building Excellance, LLC. First N~med Insured, Limited corporation Extreme Construction, First Named Insured, limited corporation General Liability Schedule of H~zards 002) ~nd Loc #00001: Carpentry, 91432, payro", 195,000 Change Exposure frOll1 65.000 to 195.000 t ... ~ . .. .~_.~.. , .... -".~""."..' . " . .'. . -0, '0.... rrf'" . -.~. " - .... ".; .-..... ~ "...,}! ',.,'''';~~'~~',n''i( ~ ~.:"':: \;;r. ~ ~('. '. 1''''r.J'''.f~\';;~ '.:;, ~~~""""4'Dd'a:a" -;i~~'':- .... ...~ '. 1~(.!rl:1i~~j~t:r~~,:~,~ t"~~:.r.l'.~J;6' \': ~.';.l:..i:,;~. ~'.' :.:-,1:"'; '" '':''i:,: .::.' { ::-~~ .'i.':~~~:/~q: ).;~~f~;i~ii;r~~j;tt".~,~~t~~~~~f1t:tf':,ltH.i,~e" ,~1.h.<t~'.~~~~. I T).J /'l':U"",,,,"1ilUu..~..~ :"".~. ~ J.,;iL~"t. . ," . . I .., ,. ....1 .,1 It I' "..ll.. '-T.I.,., 'i: ~\~. r., '.' . .~ \'" "''r~;tJ..I",~ ......'q.:~t'.&J...J~.t, '.r':;';;...'''"...~. _I ." .~~. ....(~: .' to . , I ........ 1".h"'....'.~'I...:'.I..''''.{.~:I.... ~ ..' .:.' .. .f:...,.. '." :"t"I"}..":,"""'" .):1' )~...rr:.I'...."l...:...".,...,~.. "''''.:' .. . " . f .'oS"L'~ .,.' . tit " ~,1....1_. .... . ....._. . _. .~_J."""_'___"':-_' . 1 ~__..;....:.:. .._._.._...\.._... .....\. ............ .............. Miir.V....rWlQaii..iilUir... .'. . 0.1o?.<i 1M 'M1 ~ la~l' -1 ~<o- 8 l?:>t:) 07/21/200503:03 PM 6B64E_16383 HOME OFFICE COpy DONEGAL COMPANIES MARIETTA, PENNSYLVANIA 17547-0302 COMMERCiAl PACKAGE POLICY COMMON DECLARATIONS COVERAGE IS PROVIDED BY ATLANTIC STATES INSURANCE COMPANY POUCY NUMBER: CPA8012774 Amended Policy Effective: 01/17/2005 Extreme Construction, LLC 305 High Street PO Box 335 SummerdaJe PA 17093 GUNN - MOWERY LLC POBox 900 Camp Hill PA 17001 (717)761-4600 AGENT NUMBER: 000568100 FORM OF NAMED INSURED'S BUSINESS: NAMED INSURED'S BUSINESS: Corporation Carpentry POUCY PERIOD: FROM:01/1712005 TO: 01/1712006 12:01 A.M. STANDARD llME AT THE NAMED INSURED S ADDRESS SHOWN. IN RETURN FOR THE PAYMENT OF PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. jt~~~M.r$fl~:iWi~~~~J~Mm~~~Jt~~~~~f%r~~~J~~f1~t~~~~~r@iM~m:.. ...:.~.:.' .:.. ..... ,', ....... ~...::.' . ..... .:~.t{fff:~tlt:f:r:~rjff.j~~~~$ft*?Wt~r.~~~f:WtMrf1f:~f:'f:f:~~~fJ~&1f~~f:t~~~~r:f:ft:~fJ:~~f:f:f~fJlr: This policy consists of the following coverage partes) for which a premium Is Indicated. This premium may be subject to adjustment. Commercial Property . Commercial General Uability $288 $6,808 $7,241 $4,469 DONEGAL COMPANIES MARIETTA, PENNSYLVANIA 17547-0302 POLICY NUMBER: CPA8012774 PAGE 2 :., .:Jirl:l .', Jlf . .' ?'.':' :.;! ',' JI. COMMON POLICY FORMS AND ENDORSEMENTS ARE APPLICABLE TO ALL COVERAGE PARTS, UNLESS OTHERWISE STATED IN THE FORM OR ENDORSEMENT. CMOF-600 (02-03) PoUcyholder Disclosure Notice Regarding Terrorism Insurance Coverage IlL 00 03 (04-98) Calculation of Premium IlL 0017 (11-98) Common Policy Conditions IlL 00 21 (04-98) Nuclear Energy Liability Exclusion Endorsement Broad Form IlL 01 66 (01-99) Pennsylvania Changes -Actual Cash Value Endorsement I,L 0172 (11-93) Pennsylvania Changes -IlL 02 46 (09-00) Pennsylvania Changes - Cancellation and Nonrenewal IlL 0910 (01-81) PA Notice - PA Insurance CanceD. Serv Exemption Act . IILD 90 02 (09-01) Biological and Chemical Contaminants Exclusion I PAYMENT PLAN: Account BilledlNine Pay Extreme Construction, LLC 305 High Street P. O. Box 335 Summerdale, PA 17093 STATEMENT OF ACCOUNT May 15, 2006 ~ R U1 1- \\. Y1 trt --- w 0- , ~". ,,;~, e , , \'\ ~. .- , (--- ,. ::~ -,- ..<.,. >"~:r. oj JAMES W. ADELMAN, ESQUIRE IDENTIFICATION #02604 MORRIS & ADELMAN, P.C. PO BOX 30477 Philadelphia, Pennsylvania (215) 568-5621 ATTORNEY FOR PLAINTIFF Donegal Mutual Insurance Company 19103-8477 Donegal Mutual Insurance Company 1195 River Road Marietta PA 18547 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Extreme Construction LLC 2201 N Front St Harrisburg PA 17101 NO. 06-5383 PRAECIPE TO REINSTATE COMPLAINT TO THE PROTHONOTARY: You are requested to reinstate the Complaint filed in the above-captioned matter and affect service upon Defendant(s) at the above address by deputized service on the Sheriff of Dauphin corporation. , P. C. County on Scott Peter Piotroski, an PROTHONOTARY BY: Deputy JWA0929.2 o \. ) --I f~fi C71 co .,. (:r,> SHERIFF'S RETURN - NOT FOUND CASE NO: 2006-05383 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF C~BERLAND DONEGAL MUTUAL INSURANCE CO VS EXTREME CONSTRUCTION LLC R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT EXTREME CONSTRUCTION LLC but was unable to locate Them in his bailiwick. He therefore returns the COMPLAINT & NOTICE , NOT FOUND , as to the within named DEFENDANT , EXTREME CONSTRUCTION LLC 305 HIGH STREET SUMMERDALE, PA 17093 PRE RESIDENT AT GIVEN ADDRESS, BUSINESS IS OWNED BY SCOTT PETER ~iM:S~ D~ PIOTROSKI (B)2201 N FRONT ST HARRISBURG (H)2309 FOX HOLLOW RD Sheriff's Costs: Docketing Service Not Found Surcharge 18.00 14.08 5.00 10.00 .00 _ / 47.08./ )o/f)~/o(, ~. .~ R. Thomas Kline Sheriff of Cumberland County MORRIS & ADELMAN 09/21/2006 Sworn and Subscribed to before me this day of A.D. -... '. I hereby certify that the above names are correct and Precise Business Address of the judgment creditor is Address 1195 River Road Marietta P A 18547 Address of Defendant 2201 N Front St Harrisburg PAl 71 0 1 MORRIS & ADELMAN, P.C. BY: JAMES W. ADELMAN, ESQUIRE IDENTIFICA nON #02604 P.O. Box 30477 Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 ATTORNEY FOR PLAINTIFF Donegal Mutual Insurance Compa Donegal Mutual Insurance Company 1195 River Road Marietta PA 18547 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Extreme Construction LLC 2201 N Front St Harrisburg PA 17101 NO. 06-5383 ORDER FOR ENTRY OF JUDGMENT AND ASSESSMENT OF DAMAGES TO THE PROTHONOTARY: Enter judgment in favor of the Plaintiff, Donegal Mutual Insurance Company, and against the Defendant(s), Extreme Construction LLC, in the above-entitled proceeding in the sum of$13,558.81 for failure to file an Answer, and assess damages as follows: Amount of Claim Interest from August 17, 2005 TOTAL $12,339.00 $ 1,219.81 $13, .81 DAMAGES ASSESSED AS ABOVE: , P.C. --a~~ PROTHONOT~{1 .,- . 7 ~. .10, .2oob AMES W. ADELMAN, ESQUIRE Attorneys For Plaintiff JWA1l2 1. 2 MORRIS & ADELMAN, P.C. BY: JAMES W. ADELMAN, ESQUIRE IDENTIFICATION #02604 P.O. Box 30477 Philadelphia, P A 19103-8477 (215) 568-5621 ATTORNEY FOR PLAINTIFF Donegal Mutual Insurance Company Donegal Mutual Insurance Company 1195 River Road Marietta PA 18547 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Extreme Construction LLC 2201 N Front St Harrisburg P A 17101 NO. 06-5383 CERTIFICATION I hereby certify that I sent a Notice Of Intention to file a default judgment to Defendant(s) by mail pursuant to Pa. R.C.P. 237.1, a true and correct copy of which is attached hereto as Exhibit "A." S W. ADELMAN, ttorneys For Plaintiff JWA1121.2 .. MORRIS & ADELMAN, P.c. BY: JAMES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION #02604 P.O. Box 30477 Donegal Mutual Insurance Company Philadelphia, Pennsylvania 19103-8477 (215) 568-5621 Donegal Mutual Insurance Company 1195 River Road Marietta PA 18547 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. Extreme Construction LLC 2201 N Front St Harrisburg PAl 71 0 1 NO. 06-5383 TO: Extreme Construction LLC 2201 N Front St Harrisburg P A 17101 DATE OF NOTICE: November 14, 2006 IMPORTANT NOTICE YOU ARE IN DEF AUL T BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (1 0) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOU SHOULD TAKE THIS PAPER TO YOU LAWYER AT ONCE. IF YOU DON'T HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING ALA WYER. IF YOU CAN NOT AFFORD TO HIRE ALA WYER, THIS OFFICE MAY BE ABLE TO PROVIDE INFORMATION ABOUT AGENCIES THAT MAT OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. LA WYER REFERENCE SERVICE Cumberland County Bar Association 2 Liberty Av Carlisle P A 17013 717/249-3166 jwal109.4 c A) (':) ~ ^ :--0 ~ ~ "' C) (} ~ r ~ 0 "" - = ~ ~ c: = :z; """' ~ f' =t~ l=t % ~:n 0 D pv ,,-, .." ...::;: ~Fn ~ ~ ;:~: -~~- eN ~ () ~~t-' :nO "'" ~~ ~~~- 0 0' ~ """'0 "T- -{Cl ~- -0 ;r: :n '....t... ~;~;: :x ,")-- .;....(') ......- N (Sm 2: :4 ~ Cl J> \D ~ ~ . .... OFFICE OF THE PROTHONOTARY COURT OF COMMON PLEAS CUMBERLAND COUNTY TO: EXTREME CONSTRUCTION LLC 2201 N. Front Street Harrisburg, PAl 71 0 1 DONEGAL MUTUAL INSURANCE CO. 1195 River Road Marietta, P A 18547 vs. COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION EXTREME CONSTRUCTION LLC 2201 N. Front Street Harrisburg, PAl 71 01 NO. 06-5383 NOTICE Pursuant to Rule 236 of the Supreme Court of Pennsylvania, you are hereby notified that a Judgment has been entered against you in the above proceeding as indicated below. ( ) ( ) ( ) (X) ( ) ( ) ( ) ( ) ( ) ( ) Pr~th7:t~'!':--'"'-V V ~=:t~ro::s~o~~gment) ~, ~.. DJ Judgment transferred from another jurisdiction Judgment by Default Money Judgment / _I Judgment in Replevin ,( )'16 Co Judgment for Possession Judgment on A ward of Arbitrators Judgment on Verdict Judgment on Court Findings IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE, PLEASE CALL: ATTORNEY: JAMES W. ADELMAN, ESQUIRE At this telephone number: 215-568-5621 ~.. SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2006-05383 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND DONEGAL MUTUAL INSURANCE CO VS EXTREME CONSTRUCTION LLC R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: EXTREME CONSTRUCTION LLC but was unable to locate Them in his bailiwick. He therefore deputized the sheriff of DAUPHIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On November 1st, 2006 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing Out of County Surcharge Dep Dauphin County Postage So 18.00 9.00 10.00 29.25 1. 59 67 . 84./ n If)l (p /~ L 11/01/2006 r 'II MORRIS & ADELMAN Sheriff County Sworn and subscribe to before me this day of A.D. ~ -,. . In The Court of Common Pleas of Cumberland County, Pennsylvania Donegal Mutual Insurance Canpany VS. Extrane Construction LLC No. 06-5383 civil Now, October 16, 2006 , I, SHERIFF OF CillvIBERLAND COUNTY, P A, do hereby deputize the Sheriff of Dauphin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. r~~4~~ Sheriff of Cumberland County, PA Affidavit of Service Now, ,20_, at 0' clock M. served the within upon at by handing to copy of the original a and made lmown to the contents thereof. So answers, Sheriff of County, PA Sworn and subscribed before methis_dayof ,20_ COSTS SERVICE MILEAGE AFFIDA VIT $ $ t . -.. @Hit~ of tlrr ~4r:riff William T. Tully Solicitor Charles E. Sheaffer Chief Deputy Mary Jane Snyder Real Estate Deputy Michael W. Rinehart Assistant Chief Deputy Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 780-6590 fax: (717) 255-2889 Jack Lotwick Sheriff Commonwealth of Pennsylvania DONEGAL MUTUAL INSURANCE COMPANY vs County of Dauphin EXTREME CONSTRUCTION LLC Sheriff's Return No. 1695-T - -2006 OTHER COUNTY NO. 06-5383 AND NOW:October 23, 2006 at 12: 53PM served the wi thin REINSTATED COMPLAINT upon EXTREME CONSTRUCTION LLC by personally handing to SCOTT PIOTROSKI ACCOUNTANT 1 true attested copy(ies) of the original REINSTATED COMPLAINT and making known to him/her the contents thereof at 2201 NORTH FRONT STREET HARRISBURG, PA 17101-0000 Sworn and subscribed to So Answers, JK~ before me this 24TH day of OCTOBER, 2006 NOTARIAL SEAL MARY JANE SNYDER, Notary Public Highspire, Dauphin County My Commission Expires Sept. 1,2010 Sheriff o~ oaUP:in co~n? ,Pa. ~P,' ~ ,:/ B y pf~~';f1~- .J /;c41i;;C..,,'" It" Deputy Sheriff Sheriff's Costs:$29.25 PD 10/19/2006 RCPT NO 222638 ~ HUNTER