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HomeMy WebLinkAbout06-6608 COURTNEY CAVANAUGH, a minor by JAMES CAVANAUGH AND BARBARA CAVANAUGH, her natural parents and guardians, Plaintiffs V. GORDON PANILAITIS AND MARYANN BRICKER, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL ACTION - LAW PETITION FOR APPROVAL OF MINORS' SETTLEMENT AND NOW, come Plaintiffs, Courtney Cavanaugh, a minor, by James Cavanaugh and Barbara Cavanaugh, her natural parents and guardians, by their attorneys, Freeburn & Hamilton, and petition this Court for approval of settlement. I. PARTIES 1. Plaintiff, Courtney Cavanaugh, is a minor, born April 30, 1995. 2. Plaintiffs, James Cavanaugh and Barbara Cavanaugh, are Courtney Cavanaugh's natural parents and guardians. 3. At all times relevant hereto, James and Barbara Cavanaugh had and continue to have sole physical and legal custody of Courtney Cavanaugh. 4. Defendant, Gordon Panilaitis, is an adult individual who resides at 563 F Street, Carlisle, Cumberland County, Pennsylvania. 5. Defendant, Maryann Bricker, is an adult individual who resides at 563 F Street, Carlisle, Cumberland County, Pennsylvania. II. FACTS 6. On November 18, 2005 at approximately 8:15 p.m., Plaintiff, Courtney Cavanaugh, was a passenger in an automobile operated by Plaintiff, James Cavanaugh, which was traveling east on West Willow Street, in the Borough of Carlisle, Cumberland County, Pennsylvania, 7. At that time and place, Defendant, Gordon Panilaitis, who was operating an automobile owned by Defendant, Maryann Bricker, was traveling south on South Pitt Street, in Carlisle, Cumberland County, Pennsylvania, and failed to stop at a red traffic signal and proceeded into the intersection into the path of the vehicle operated by Plaintiff, James Cavanaugh. 8. The automobile that Defendant, Gordon Panilaitis, was operating was insured under an automobile insurance policy issued by Safe Auto Insurance Company ("Safe Auto") 9. Safe auto has denied coverage for Defendant, Gordon Panilaitis. III. INJURIES 10. Courtney Cavanaugh treated at Casses Chiropractic Clinic from 11/21/05 through 3/22/06 for right shoulder injury, thoracic sprain/strain and rotator cuff sprain/strain. 11. Courtney Cavanaugh has obtained a satisfactory recovery from her injuries. 2 N. INSURANCE COVERAGE 12. Plaintiff, Courtney Cavanaugh, was insured under an automobile insurance policy issued by Liberty Mutual Insurance Company to James and Barbara Cavanaugh. 13. The Liberty Mutual Insurance Company policy had a medical benefits coverage limit up to $5,000.00. A true and correct copy of the declarations page for said policy is attached hereto as Exhibit "A." V. MEDICAL EXPENSES 14. The medical* charges for Courtney Cavanaugh's medical treatment have all been paid for by Liberty Mutual Insurance Company. A copy of the payout log from Liberty Mutual Insurance Company is attached hereto as Exhibit "B." 15. Plaintiffs have made a claim for uninsured motorist benefits under the automobile insurance policy issued by Liberty Mutual Insurance Company. VII. SETTLEMENT 16. Liberty Mutual Insurance Company has offered to settle Courtney Cavanaugh's uninsured motorist claim for the total sum of $5,000.00. A true and correct copy of a proposed release is attached hereto as Exhibit "C." 17. Plaintiffs, James and Barbara Cavanaugh, have reviewed the proposed release by Liberty Mutual Insurance Company with their attorneys and are satisfied that they understand all of its terms and the consequences of signing it. 3 18. James and Barbara Cavanaugh signed a contingent fee agreement with Freeburn & Hamilton with respect to Courtney's claims for 25 percent of the gross settlement proceeds, plus expenses. A true and correct copy of the Attorney's Agreement is attached hereto as Exhibit "D." 19. The settlement proceeds for Courtney Cavanaugh would be distributed as follows: Total settlement of $5,000.00 1. $1,250.00 to be paid to Freeburn & Hamilton pursuant to its 25 percent fee agreement; 2. Freeburn & Hamilton waives its claim for reimbursement of expenses which were as follows: a. Casses Chiropractic Clinic $79.27 b. Cumberland County Prothonotary $55.50 3. The net settlement proceeds in the sum of $3,750.00 would be deposited in a savings account in the name of Courtney Cavanaugh with Sovereign Bank, Mechanicsburg, Pennsylvania, which is insured by the FDIC. A hold would be placed on the account so that no transfers or withdrawals could be made from the account until Courtney Cavanaugh attains her majority, except as authorized by a prior Order of Court. Sovereign Bank has agreed to comply with these directions. 20. James and Barbara Cavanaugh believe that this settlement is in the best interest of Courtney Cavanaugh because it avoids the risk of obtaining a lesser recovery or no recovery at all, and avoids further expense and delay of litigation. 4 WHEREFORE, Petitioners hereby request that this Honorable Court enter an Order: (a) Approving the full and final settlement of this action; (b) Authorizing James and Barbara Cavanaugh to sign all documents necessary to accomplish the settlement, including but not limited to the Settlement Agreement and Full and Final Release on behalf of Courtney Cavanaugh, a minor; (c) Approving the distribution of the settlement proceeds as set forth herein; (d) Directing payment of the net fund to be made in the name of Courtney Cavanaugh with Sovereign Bank; and (e) Staying all proceedings meanwhile. Respectfully submitted, FREEBURN & HAMILTON By: Ric and . Freeburn, Esquire I.D. No. 30965 4415 North Front Street Harrisburg, PA 17110 (717) 671-1955 Dated: 11/13/06 Attorney for Petitioners 5 VERIFICATION We hereby verify that the statements in the foregoing document are true and correct. We understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Dated: N- I -6l a C.?v Barbara Cavanaugh LibertyGuard Auto Policy Declarations Liberty The First Liberty Insurance Corporation MjitU? Boston, Massachusetts YOUR POLICY NUMBER: A06-288-132035-70 5 0 NAMED INSURED AND MAILING ADDRESS: JAMES CAVANAUGH BARBARA CAVANAUGH 315 N HANOVER ST CARLISLE PA 17013-1928 15, 0 0 0 Each person 3 0, 0 0 0 Each Accident SERVICE: 800 - 225 - 7014 CLAIMS: 800-2CLAIMS (800-225-2467) Members@ Auto and Homeowners Insurance Program Belco Community Credit Union Policy Period: 03/15/05 to 03/15/06 12:01AM Standard Time at the Address of the Named Insured as Stated in the Policy. Reason For This Notice: Change Class Veh 1 Endorsement 01 Add Veh 3 Premium Adjustment From 07/20/05 to 03/15/06: Veh 1 Veh 2 Veh 3 $ 50CR 348 Total Adjustment: $ 298.00 PERSONAL AUIOMOBILE COVERAGE, LIMITS, AND PREMIUM Coverages And Limits Under Your Auto Policy: Part A. Liability Bodily Injury $ 15, 0 0 0 Each person $ 3 0, 0 0 0 Each Accident Property Damage $ 5,0 00 Each Accident v. VLliiia Yi Rb i'J?J WII?VD Bodily Injury $ Underinsured Motorists Bodily Injury $ $ Full Tort Option Selected First Party Benefits 5,000 Medical Expense 0 Funeral Expense 0 Income Loss 0 Accidental Death D. Coverage For Damage To Your Auto Collision Actual Cash Value Less Deductible Shown: Veh 1 $ 500 Veh 2 $ 500 Veh 3 $ 500 AUTO 70791 Ed. 4-91 ?4( f. 11, CREPAR, ZA? ' ESIDENTe4L 15 , 0 0 0 Each person 3 0, 0 0 0 Each Accident THESE DECLARATIONS EFFECTIVE : 07/20/05 FOR SERVICE PLEASE CONTACT: 2501 WILMINGTON ROAD NEW CASTLE PA 16105 Coverage Is Provided Where A Premium Is Shown For The Coverage Veh 1 Veh 2 Veh 3 $ 162 189 199 $ 18 18 18 $ 35 35 35 $ 41 41 44 $ 176 222 160 This policy, including all endorsements attached is countersigned by: AUTHORIZED REPRESENTATIVE LibertyGuard Auto Policy Declarations Page 2 The First Liberty Insurance Corporation Boston, Massachusetts YOUR POLICY NUMBER : A06 - 2 8 8- 132035 -7 05 0 THESE DECLARATIONS EFFECTIVE: 07/20/05 (Continued from Previous Pag This Policy Covers Collision Damage To Rental Vehicles. Other Than Collision $ 66 73 41 Actual Cash Value Less Deductible Shown: Veh 1 $ 100 Veh 2 $ 100 Veh 3 100 Increased Transrortation 00 36 36 rujnual rziamiu n rer vena.c.te: $ 498 614 533 Safe Driver Insurance Plan Credit: As A Result Of : Violation SCO NO Surcharge Accident SCC NO Surcharge Total Annual Policy Premium: $ 1645.00 VEHICLES COVERED BY YOUR POLICY Vehicle Veh Year Make Model ID Number 1 1994 CHEVROLE T SUBRBN25 1GNGK26K4RJ438029 2 1998 FORD WINDSTAR 2FMZA5147WBC13730 3 1995 PONTIAC BONNEV S 1G2HX52K2S4248261 Loss Payee(s): Month/Year Expires: VEH 2 PSECU 04/2007 VEH 3 PCU 07/2008 DRIVER INFORMATION Driver Name DOB State License Number JAMES CAVANAUGH 10/24/69 PA 23856870 BARBARA CAVANAUGH 07/21/70 PA 22196011 To Ensure Proper Coverage, Please Contact Us To Add Drive rs Not Listed Above. VEHICLE DISCOUNTS INCLUDED IN YOUR RATE Discounts Veh 1 Veh 2 Veh 3 Anti-Lock Braking System Yes Anti-Theft Device(s) No Passive Restraint Yes (Automatic Seats Belt and/or Air Bags) Yes Yes No Yes Yes Yes OTHER DISCOUNTS INCLUDED IN YOUR RATE Multi-Car MembersO Auto And Homeowners Insurance Program AUTO 3079 (Ed. 4-93) SECRE7ARY? ? PRESIDENT This policy, including all endorsements attached is countersigned by: j4v7'6m/-- AUTHORIZED REPRESENTATIVE AL'_ STAIF LEGAL 8001-1 p310 EllI RECYCLED 'cxl„br? 3 Nov 7 2006 15:01 Insured: Occurrence Number. Date of Loss: . "" ' Claimant: "' *Mahimrseio ont NuMb?. ..Coverage . Damage_Amoumt Adjustment Amount Adjustment Reason Amount NF'MP 55.00 .0.12 99 54.88 P. 02 Page 1 of 11 Total Payment Amount: 54.88 Pay k-'Om: 2006-03-22 Pay Through: 2006-03-22 Deductible Amount 0.00 Adjustment Reason Descriptions - •AuthorUe-Amount:.. ..54.88 99.-Offer Wit6holding Amount: 0.00 Disbursewnent Amount: 54.88 EOP Note: Bi U Jm4ge Control plumber-71000602140 Disbursement Number: 17611802 Date: 2006-04-18 Amount: 85.91 ayee:.SCOTr D.CASSES ayee Address. 3.13 S HANOIVER ST, CARLISLE, PA 17013 .Coverage Damage Am.onat Adjustment Amount Adjustment Reason Amount 1VF1? 43.00. 4.29 99 38.71 1vkMP . 29.00 5.80 180 2320 NFMP 30.00 ..6.00 1s0 24.00 Total Paymeiat .AIDOl1nt: 85.91 Pay From: 2006-03-15 Pay Through; 2006-03-15 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount: 85.9.1 99 = Other Withholding Amount: 0.00 180 - PAX SO%. OI~ BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount; 85.91 80% OF THE PROW)EWS BELLED CHARGES_ % IEOP Note: Bill lxoa a Cozltrol Number-71000601450 TAMES CAVANAUGH LA830-006605953-0004 2005-11-18 COURTNEY CAVANAUGH _ 17631394 Date: 2006-04-21 Amount; 54.88 SCOTT D CASSES Address: 313 S HANOVER ST, CARLISLE, PA 17013 hops://pxn CheekRegisterl:cheekQO] ?a)proclaims-internal.lxxyig.eoioa/CheckRegiste?rlFinauc... 11/7/2006 Nov 7 2006 15:01 P.03 Page 2 of, 11 Disbarsemesat Number: 17605126 Date: 2006-04-17 Amount: 64.43 •Payee: -CUASTI Y A KELLER"DC ayee:Addrew. 313 S HANOVBR ST, CARLISLE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 43.00 13.97 99,97 29.03 Nk'W . 30.00 .12.00 180,97 18.00 NFMF 29.00 .11.60 180,97 17.40 Total Payment Amount: 64.43 Pay.From: 2006-03-10 Pay Through: 2006-03-10 Deductible Amount 0.00 ,A,djustment Reason Descriptions _ •Authorize Amount: .64 43 „99 -'Other Withholding Amount: 0.00 97-$ee Notes for Adjustment Desc4tion Disbursement Amount 64.43 180 - PAY 80% OF BILLED CHARGE PAYUMNT WAS CALCULATED AT 8(rOF THE PROVII)EWS BILLED CHARGES. EOP Note: PPO Reduction = $21.48 Bull Image Control Number-70900603872 Fees reduced per CCN PPO contractual allowance. If u have an uestions Mmdiqg this allowance call 1-800-937-6824. 17528074 Date: 2006-03-30 Amount: 74.41 Disbursement Number: Payee: SCOTT D CASSES Payee Address; 313 S HANOVM ST, CARLISLE, PA 17013 Coverage, Damage,kwount Adjustment Amount Adjustment Reason Amount NFMP., 43.00 429 99 38.71 Nk7.V1P 29.00 5.80 180 23.20 NFMP 30.00 17.50 99 12.50 Total Payment Amount: 74.41 Pay From: 2006-02-17 Pay Throiio- 2006-02.17 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount: 74.41 99' Other Withholding Amount: 0.00 180 - PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount:. 74AI 80% OF THE PROVII]EWS BILLED CHARGES. EOP Note: Bill Image Comol Numbest-70740601092 hitpsJ/pn CbeckRegisterl:check00I@,pmelainis-intestinal.Imig.com/ClaeckRegitster./Finane... 11/7/2006 Nov 7 2006 15:01 P.04 Page 3 of 11 Disbursement Number- 17463869 Date: 2006-03-17 Amount: 74.93 . ayee: SCOTTD.WSES Payee Address:.. 313 S HANOVER ST,. CARLISLB, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 43.00 3.77 99 39.23 NFMP 29.00 5.80 180 2320 . NFMP 30.00 17.50 99 12.50 Total Payment Amount: 74.93 Pay From.: 2006-02-03 Pay Through: 2006-02-03 Deductihle. Amount:, ..0.00 Adjustment Reason Descriptions Authorize Amount: 74.93 99 -.Other Withholding Amount: 0.00 180 - PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74.93 80% OF THE PROVIDEWS BILLED CHARGES. EOP Note: Bill Im a Control Number-70590600079 Disbursement. Number. 17457277 Date: 2006-03-16 Amount; 117.43 Payee: SCOTT D CASSES Payee Address: 313 S HANOVFk ST, CARLISLE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 43.00 3.77 99 39.23 N1aN1P 55.00 0.00 55.00 NFMP 29.00 5.80 1so 23.20 Total Payment -Amount. 117.43 Pay From: 2006-01-25 Pay Thr ough: 2006-01-25 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount: 117.43 99 = Other Withholding Amount: 0.00 180 -PAY 80% OF 13ILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 117.43 800/o OF TIM PROVIDER'S BALLED CHARGES- ,pmcW=s-iuternal.Imig.com/CheckRegister/Financ"- 117772006 Nov 7 2006 15:01 P.05 Page 4 of 11 -Mbursement Number: 17457278 Date: 2006-03-16 Amount: 74.93 Payee: SCOTT D LASSES Payee Address: 313 S HANOVER ST, CARLISLE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP.. 43.00 3.77 99 3923 NkMP.::... 29.00 .5.80 180 23.20 NFIvjP 30.00 17.50 99 12.50 Total Payment Amount: 74.93 Pay From: 2006-02-08 Pay Tbrougb o ' 2006-02-08 Deductible Amount; 0.00 Adjustment Reason. Descriptions Authorize Amount: 74.93 99 -.Other Withholding Amount: 0.00 . 180 - PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74.93 80% OF THE PROVIDEWS BILLED CHARGES. OP Note: Bill Image Control Number-70590600076 Disbursement Number: 17364207 Date: 2006-02-27 Amount: ' 74.41 Payee: SCOTT D CASSES Payee Address: 313 S.HANOVER ST, CARLISLE, PA 17013 ..Coverage.. Damage.Amount Adjustment Amount Adjustment Reason Amount' NFMP 43.00 4.29 99 38.71 N1 MMP 29.00 5.80 180 23:20 NkMP 30.00. .17.50 99 12.50 Total Payment Amount;, 74-41 Pay From: 2006-01-18 Pay Through: 2006-01-1$ .Deductible Amount: 0.00 Adjustment Reason Descriptions . Authorkw Amount., 74.41 99 - Other Withholding Amount. 0.00 180- PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74.41 80%% OF THE PROVIDER'S BILLED CHARGES. https:llpm ChockRegistal:check001(a- pmclaims-intemal.bxdg.comICheckRegistezxlFinanc... 11/7/2006 Nov 7 2006 15:01 P.06 Page 5 of 11 Disbursement Number: 17321644 Date: 2006-02-17 Amount: 74.41 Payee: SCOTT D CASSES Payee Address:, 313 S HANOVER ST, CARLISLE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 30.00 17.50 99 12.50 IM& .. 29.00 5.80 180 23.20 NF'MP-. 43.00 .4.29 99 38.71 Total Payment Amount: 74.41 Pay From: 2006-01-06 Pay Through: 2006-01-06 Deductible Amount! 0.00 Adjustment Reason Descriptions Authorize Amount: 74.41 99- Other Withholding Amount: 0.00 180 - PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74AI 80% OF THE PROVIDER'S BILLED CHARGES. Disbursement Number- 17229355 Date: 2006-01-31 Amount: 72.66 Payee: SCOTT D CASSES Payee Address: 313. S HANOVER ST, CARLISLE, PA 17013 Coverage. Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 43.00 6.04 99 36.96.. NFW .29.00 5.80 180 23.20 NFMP 30.00 17.50 99 12.50 Total Payment Amount: 72.66 Pay From: 2006-01-04 Pay Through: 2006-01-04 Deductible Amount: 0.00 Adjustment Reason. Descriptions Authorize Amount: 72.66 99 - Other Withholding Amount: 0.00 180 - PAY SO% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 72.66 80% OF THE PROVIDER'S BILLED CHARGES- .. OP Note: Hill Ina je C6nti0_ f lumber-70180600642 https://pnm_CbEeckRegisterl:checkOOI @pmclaims-internal.Imig.com/CheckRegister/Finane... 11/7/2006 Nov 7 2006 15:02 P.07 Page 6 of 11 Disbursement Number: 17229354 Date: 2006-01-31 Amount: 222-52 Payee: SCOTT D CASSES Payee Address: 313 S HANOVER ST, CARLISLE, PA 17013 Damage Amount Coverage Adjustment Amount Adjustment Reason Amount .. . NFMP 30.00 17.50 99 12.50 Nk'lV 29.00 5.80 180 23.20 NFW...... ... -43,00 .3.77 99 39.23 43.00 NFMP : :3.77 99 39.23 . . : 29.00 14 F1vlP 5.80 180 23.20 . .NFMP .., .. 30.00. 17.50 99 12.50 NF1viP 43.00 .6.04 99 36.96 NFM,' 29.00 5.80 180 23.20 ?I NFMP 30.00 17.50 99 12.50 Total Payment Amount: 222.52 Pa ; From, - 2005-12-27 Pay Through. 2006-01-02 Deductible Amount: 0.00 Adjustment Reason. Descriptions Anthorize Amount: 222.52 99 - Other Withholding Amount: 0.00 180 - PAY 80*/o OF BILLED CHARGE pA MErTI' WAS CALCULATED AT Disbu n*ment ,Amount: 222.52 80% OF THE PROVIDER'S BILLED CHARGES. OP Note: Bill lm a CoUMI Nuamber-70110600081 Disbursement Number: 17184670 Date: 2006-01-23 Amount: 7433' Payee: SCOTT D CASSBs ;Payee Address: 313. S HANOVER ST, CARLISLE, PA 17013 . Coverage. Damage Amount Adjustment Amount Adjustment RA912on Amount NFMP 30.00 17.50 99 12.50 N1~'W ... 29.00 5.80 1$0 23.20 NFUT 43.00 3.77 99 39.23 Total Payiuaent.Amount: 74.93 Pay From: 2005-12-23 Pay Through: 2005-12-23 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount: 74.93 99':- Oilier Withholding Amount: ..0.00 180 - PAY 809/6 OF BILLED CHAitGE PAYMENT WAS CALCULATED AT Disbursement. Amount:. 74.93 go% OF TIF PROVIDER'S BILLED CHARGES. Mips://.pnk_CheckRegisterl :cheek001 [a pmclai=-internal-bnig.cona/CheckRegister/Financ... 11/7/2006 . . Nov 7 2006 15:02 P.08 Page 7 of 11 Disbursement Number: 17169816 Date: 2006-01-19 Amount: 74.93 Payee: SCOT'T D CASSES Payee Address: 3133 HANOVER ST, CARLISLE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount .NFMP-. .30-00 .. 17.50 99 12.50 NFW 43.00 3.77 99 39,23 NF'lvD.' 29.00 .5.80 180 23.20 Total Payment Amounts 74.93 Pay From: 2005.12-16 Pay Through: 2005-12-16 Deductible Amount: 0.00 Adjustment Reason Descriptions Aatharbz Amount: 74.93 99 -:Other Withholding Amount:. 0.00. 180 - PAY $0% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount., 74.93 80% OF THE PROVIDEWS BILLED CIIARGES. OP Note: Bill YgMe Control 3qumber-7005060087 Disbursement Number. .17169817 Bate: 2006-01-19 Amount: 74.93 syee:.SCOTT D CASSES....... .... . Yee Address: 313 S.HANOVER ST, CARLISLE, PA 17013 Coverage . Damage Amoamt Adjustment Amount Adjustment Reason Amount NFW 30.09 17.50 99 12.50 NF1v1P... ......... 29.00 5.80 180 2320 NFW 43.00 3.77 99 3923 Total Payment Amount 74.93 Pay From.: 2005-12-20 Pay Through.: 2005-12-20 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount: 74.93 99 = Other Withholding Amount: 0.00 180 - PAY 8o•/u OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74.93 80% OF THE PROVIDEWS BILLED CHARGES. EOP Note: Bi111ma Control Number-70090600665 https://pm_ClaeckRegister ;check001 a pmclaaxns-intenctal.lmig.conVCheckRegister/Fina c... 11/7/2006 Nov 7 2006 15:02 P.09 Page 8 of 11 :y:1e1,:.rS5CCM(0:,,-7, lumber: 17155441 Date: 2006-01-17 ,Amount. 74.93 T D LASSES Payee Address: 313 S HANOVER ST, C ARLISLE, PA 170X3 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 30.00 1750 99 12.50 Mp........ .43.00. 3.77 99 39.23 S.SQ 180 2320 .....?p,Ip.._ ..... .29.00 ..... . _ ... _ . .... .... 2005-12-14 . 't'otal payment Amount; 74.93 Fay From: 2005.1214 Fay Through; Deductible Amount: 0.00 Adjustment Reason Descriptions AaWarize Amount:. 74.93 99 -.Other Withholding Amount: 0.00 180 PAY SO% OF BILLED CITARGF PAYMENT WAS CALCULATED AT Disbursement Amount: 74.93 80% OF THE PROVIDER'S BILLED CHARGES. Disbursement Number: 17148259 Date: 2006-01-16 Amount: 74:93 Payee: SCOTT D CASSES 17013 we Address: 313 &HANOVER ST, CARLISLE, FA Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 30.00 17.50 99 12.50 NFMP 29.00 5.80 180 23.20 3lFMP 43.00 .. 177 99 3923 Total Payment Amount;, 74.93 2005-12-07 ray FYom: 2005-12-07 Pay Through: Deductible Agnoant: 0,00 Adjustment Reason Descriptions Authorize Amount: 74.93 99!', Other LED MENT WAS CALCULATED AT PAY 80% E P OF 13EL 180 Withholding Amount: 0.00 - CHARGES R BILL ED OF THE P Disbursement Amount: 74.93 EOP.. Note: Bill Image Control Number-73570500754 ane: 11!712006 https://pm CheekRegisterl:cheekool@pmclaims-intemal._lxnig.col /checkRegister/Fin..- _ Nov 7 2006 15:02 P. 10 Page 9 of Y Disbursement Number: 17148260 Date: 2006-01-16 Amount: 74.93' Payee: SCOTT D CASSES Payee Address: 313 S HANOVER ST, CARLISIL F-, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NF1v1P 30.00 17.50 99 12.50 .... ..... NFMP 29.00 .5.80 180 2310 _ .. NFMP . .43.00.......... . . 3.77. 99 39.23 Total Payment Amount: 7493 Pay From: 2005-12-09 Pay Through: 2005-12-09 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount: 74.93 99 -.Other Withholding Amount: 0.00 180 - PAX 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74.93 80% OF THE PROVIDER'S BILJ-lrD CRARQES. EOP Note: Bill bon j e Control Number-73570500654 Disbursement Number. 1714826.1 Date: 2006-01-16 Amount: 74.93 Payee: SCOOT X D.CAS$ES.. ... . 14yee Address: 313. S HA?TOVEIt ST,. CA1t1.I5LE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason. Amount NFMP 43.00 3.77 99 3923 NFlvlP 29.00 5.80 180 23.20 NFMP 30.00 .17,50 99 12.50 Total Pay' at Amount: 74.93 Pay From:. 2005-12-12 Pay Through: 2005-12-12 Deductible Amount: 0.00 Adjustment Reason. Descriptions Authorize Amount: 74.93 99 - Other Withholding Amount: 0.00 1$0 - PAX $0% OF BILLED CHARGE PAYMENT WAS CALCULATED AT Disbursement Amount: 74.93 $0% OF THE OROVIDER S BILLED CHARGES. aps://.Pm_CheckRegisterl :check001 @,pmclaims-iuaternal.lmig.com/CheckRegisterlFirianc.:. 11/7/2006 ,I P. 11 Page 10 of 11 - - Disbn?rsement dumber: 17103783 Date: 2006-01-06 Amount: 63.57 Payee: SCOTT D CA.SSES ayes Address:.313 S FIANOVER ST CARLISLE, PA 17013 Coverage, . Damage Amount Adjustment Amount Adjustment Reason Amount 34.00 6.13 99 27.87 NFMP 29.00 5.80 180 23.20 NFW 30.00 17.50 99 12.50 Total Payment Amount: 63.57 Deductible Amount 0.00 Authorize Amount;... _63.57 Withholding Amount: 0.00 "Disbursement' Amount: 6367. EOP Note: Hill bmue Cool N1 Pay From: 2005-12-W fay Through: 2005-12-06 Adjustment Reason Descriptions 99 -,Other 180 - PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT 800/6 OF THE PROVIDER'S BILLED CHARGES. imbeC-73530500732 Explanation of review to follow. Disbursement Number: 17088776 Date: 2006-01-04 , Amount: 56.20 Payee: CHASTITY A'KELLER DC Payee Address: 313: S HANOVER ST, CARLISLE, PA 17013 ..Coverage Damage Amount Adjustment Amount Adjustment Reason Amount 1r1FMp, .... 43.00 .13.58 99,97 29.42 NFMP 30.00 .20.62 99,97 9.38 N'FMP 29.00 .11.60, . 180,97 17.40 Total Payment Amount, 56.20 Pay From., 2005-11-28 Pay Through: 2005-11-28 Deductible Amount: 0.00 Adjustment Reason Descriptions Authorize Amount. . 56.20 99 - Other Withholding Amount: 0.00 97-See Notes far Adjustment Description Disbursement Amount: 56.20 180 - PAY 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT ' 80% OF THE PROVIDER'S BILLED CHARGES. EOP Note: PPO Reduction = $18.73 Bill Image Control Number-73530500730 Fees reduced per CCN 'PPO contractual Nov 7 2006 15:02 httpsJ/pn _CheckR.egisterl:check-001(apmclaims-internal.brig.com/CheckRegister/Financ... 11/7/2006 Nov 7 2006 15:02 P.12 Page 11 of 11 Disbursement Number: 17088768 Date: 2006-01-04 Amount: 236.73 payee: SCOTT D CA,SSES Payee Address. 313 S HANOVER ST, CARLISLE, PA 17013 .Coverage Damage Amount Adjustnac at Amount Adjustment Reason Amount Np........ 43.00. .. .3.77 99 39.23 NFMP 29.00 5.80 180 23.20 NFMP 30.00 .17.50 99 12.50 NFMP 90.00 3.13 99 86.87 WNW 43.00 .3.77 99 3923 NFNR 29.00. .5.80 180 2320 NFMP 30.00 17.50 99 12.50 Total Payment Amount: 236.73 Pay Rrom: 2005-11-21 Pay Through: 2005-11-25 Deductible Amount: . 0.00 Adjustment Reason Deseriptious Authorise Amount: 236.73 99 =. Other Wittbholding Amount: 0.00. 180: - PAY 80%.OF BILLED CIIARGIr PAYMENT WAS CALCULATED AT Disbursement Amount: 236.73 80% OF THE PROVIDER'S BILLED CHARGES- EOP Note: Bill image Control Number-73550500008 Disbursement Number: 17088777 Date: 2006-01-04 Amount: 112.40 Payee: CHASTITY AXELI..FR DC Pavee .Address: 313 S HANOVER ST, CARLISLE, PA 17013 Coverage Damage Amount Adjustment Amount Adjustment Reason Amount NFMP 43.00 13.58 99,97 29.42 NFW 30.00 20.62 99,97 938 NFMP 29.00 11.60 190,97 17.40 NFMP 30.00 20.62 99,97 9.38 NEW 43.00 13.58 99,97 29.42 NFNW 29.00 11.60 180,97 17.40 Total Payment Amount: 112.40 pay From, 2005-11-30 Pay Through: 2005-12-02 Deductible Amount: 0.00 Adjustment Reasou'Descriptions Authorize Amount: 112.40 99'- Other .Withholdi ag.Amouut:. .0.00.. 977See Notes for Adjustment Description Disbursement Amount: 112.40 180 - PAX 80% OF BILLED CHARGE PAYMENT WAS CALCULATED AT 801% OF TIME MOVIDEWS BILLED CHARGES. EOP Note: PPO Reduction = 537.46 Bill Image Control plumber-73530500733 Fees reduced per CCN FPO contractual allowance. If you have an questions regwxfing this allowance call 1-800-937-6824. bttps://pm CheckRegisterl:c eck001 c, mclaims-iuaternal.lnoig.cem/Chec?kRegiste?r/Pinane... I IM2006 ALL-STATE 'IEGAL 000-222- 510 ED,, RECYCLED CLAIM NUMBER: LA830-006605953-13 11/18/2005 DATE OF LOSS: RELEASE AND TRUST AGREEMENT I/We, the undersigned, James and James and Barbara Cavanaugh as parents/guardians of Courtney Cavanaugh, being of full age, for the sole consideration of five thousand ($5000.00) paid by The First Liberty Insurance Corporation (hereinafter referred to as LIBERTY), the receipt of which is hereby acknowledged, hereby releases, acquits, and forever discharges LIBERTY under Uninsured Motorist Coverage of its Policy Number A06-288-132035-70 arising out of an accident that occurred on 11/18/2005 at or near SOUTH PITT STREET & WEST WILLOW STREET, CARLISLE, PA. The undersigned further agrees to do whatever is proper to secure any rights he/she may have against any party who may be legally liable for the damages sustained by the undersigned in said accident, including taking in his/her own name any action necessary or appropriate to recover such damages. In the event of such recovery by judgment or settlement, the undersigned shall reimburse LIBERTY, to the extent of its payments hereunder, less a pro-rata share of the cost of securing such judgment or settlement, out of the proceeds of such recovery. The undersigned shall notify LIBERTY of all significant developments in any action undertaken to secure the undersigned's rights and shall execute and deliver to LIBERTY such instruments and papers as may be appropriate to secure the rights and obligations of the undersigned and LIBERTY established by the provisions of this agreement. PLEASE READ BEFORE SIGNING This is a release and you are making a final settlement. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Done in the City of In the presence of: this day of in the year Witness Signature Signature Address of Witness Address Witness Signature Signature Address of Witness Address Helping People Live Safer, More Secure Lives ASC93B ALL-STATE'LEGAL 800-222-0510 ED11 RECYCLED Exl,?bi1 ? FREEBURN & HAMILTON ATTORNEY'S AGREEMENT THIS AGREEMENT entered into this '31D day of September, 2006 by and between FREEBURN & HAMILTON, Attorneys-at-Law (hereinafter referred to as "Attorney") and JAMES CAVANAUGH AND BARBARA CAVANAUGH, INDIVIDUALLY AND ON BEHALF OF COURTNEY CAVANAUGH, THEIR MINOR DAUGHTER, her successors and assigns (hereinafter referred to as "Client"). WITNESSETH: That Attorney, for the consideration hereinafter stipulated, has undertaken and does hereby undertake and agree with Client(s) to act as legal counsel in negotiating settlement of third party claims and or claims for uninsured or underinsured motorist benefits, and if the same is not effected, in bringing, conducting and prosecuting actions, including but not limited to, actions for uninsured and Underinsured motorist benefits against all parties that they determine may be liable for damages as a result of the personal injuries which occurred on or about 11/18/05 ATTORNEY FEES: In consideration for services so rendered by Attorney, it is hereby agreed by and between the parties hereto that Attorney shall be compensated as follows: TWENTY-FIVE PERCENT (25%) of gross recovery if your case is settled before papers are filed with the court to list it for trial. "Gross recovery" shall mean the full amount of settlement proceeds or the full amount of verdict, including any pre- judgment interest, without reduction for expenses or costs advanced or incurred. THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of gross recovery after papers are filed with the court to list it for trial. If the proceeding is not the type of proceeding where papers are filed with the court to list it for trial, then commencement of trial is when the hearing begins. If Client(s) receive, via settlement or litigation, a dollar amount that includes reimbursement for Attorneys' fees, compensation of Attorneys shall be based on the percentages as set forth above. Any award of attorneys' fees that is required by law or order of Court to be computed on an hourly basis shall be billed at Two Hundred and Fifty ($250.00) Dollars per hour for Attorneys and Ninety Five ($95.00) per hour for law clerks and paralegals. If you enter into a structured settlement agreement, our fee will be based on the applicable percentage determined as above, applied to the sum of any cash paid in settlement plus the present cash value of the structured portion of the settlement, and payable in full from the cash portion of the settlement. If any additional work is required by us after resolution of the case, either as consultants, witnesses or otherwise, we will be compensated for such work at our regular hourly rates, and for costs incurred. ATTORNEY'S LIEN: Attorney shall have alien for attorneys' fees and for costs advanced and expenses incurred on any sum or sums recovered, whether by settlement or judgment. Should this agreement be breached or otherwise terminated by Client prior to the resolution of the claim, Client shall reimburse Attorney for any costs advanced by Attorney up to the time of the breach or termination, and Attorney shall have alien on any sum or sums finally recovered in the amount of THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of any settlement offer in existence at the time of Client's breach or termination. In order to secure payment of the said fee, Client hereby assigns the said sum to Attorney out of the proceeds finally recovered. Should Attorney discharge Client or withdraw on the grounds set forth below, Client shall reimburse Attorney for any costs advanced by Attorney up to the time of discharge or withdrawal, and Attorney shall have a lien on any sum or sums finally recovered in the amount of THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of any offer of settlement in existence at the time of discharge or withdrawal. In order to secure payment of the said fee, Client hereby assigns the said sum to Attorney out of the proceeds finally recovered. EXPENSES: Any necessary and reasonable costs advanced by Attorney in the preparation and presentation of Client's claim, and all expenses attendant thereto, shall be reimbursed from the proceeds of any recovery. Except as set forth above with respect termination of this agreement prior to resolution of the case, Client shall have no obligation to reimburse Attorney for such expenses if no recovery is obtained. LEGAL REPRESENTATION It is understood that FREEBURN & HAMILTON represents Client with respect to third party claims and/or underinsured or uninsured motorist claims only, and that FREEBURN & HAMILTON does not represent Client with respect to any other matter including but not limited to property damage claims, insurance claims, claims for governmental benefits such as social security benefits, or workers' compensation claims, unless and until a separate written agreement is signed by both Client and FREEBURN & HAMILTON, whereby Freeburn & Hamilton agrees to represent Client on such other matter. In particular, Client understands and agrees that discussion of other legal matters with any representative of FREEBURN & HAMILTON, including it's attorneys or staff or statements made by staff or attorneys of FREEBURN & HAMILTON regarding other legal matters do not constitute an agreement by FREEBURN & HAMILTON to represent Client concerning such other legal matter or that FREEBURN & HAMILTON will take any action to protect Client's rights with respect to such other legal matters. This provision cannot be modified by oral statements or by conduct on the part of FREEBURN & HAMILTON. Client also understands that other legal matters have time limits within which suit must be brought or actions taken, and that the failure to file suit or take such actions will result in the loss of Client's rights. Client understands and agrees that FREEBURN & HAMILTON will not file suit or take any action to protect Client's rights on any other legal matter unless and until a separate written agreement is signed by both Client and FREEBURN & HAMILTON, whereby FREEBURN & HAMILTON agrees to represent Client on such other legal matter. We will try to keep you currently informed of the status and progress of the case, but if at any time you have questions or concerns about the case, please feel free to contact us. We will furnish you with copies of pertinent documents and correspondence in a reasonably timely manner. You agree to keep us currently informed as to your condition and any pertinent developments that come to your attention. The decision to file suit and to list for trial shall be made by you in consultation with us. We will make a reasonable effort to retain significant papers in the file for a reasonable period after the conclusion of the matter. All of our work product will be owned and retained by us. Original documents and other tangible things furnished to us by you will be returned to you at your request at the end or our work and upon payment of any sums due us, unless such items are consumed in the course of our work. Legal representation contemplated herein does not include appeals or post trial motions, but is limited to work up to a verdict or award. We shall have the right but not the obligation, to prosecute or defend any appeals or post trial motions or both that we, in our sole discretion, deem expedient, economical or advisable, or to decline to do so in which event the representation provided for herein shall be ended. SETTLEMENT PROVISIONS: Client(s) will not settle, adjust proceedings in connection therewith, Attorney. Client(s) further agree to settlement made by Attorney and not settlement. or compromise the above claim, or any without the advice and written consent of consider seriously any recommendation for to unreasonably withhold consent to such DISCHARGE OR WITHDRAWAL: In the event that Attorney subsequently determines that the claim or suit lacks merit, or Client(s) unreasonably withhold consent to any bona fide settlement recommendation made by Attorney, or Client(s) refuse or fail to cooperate with Attorney, or Client(s) conceal or misrepresent facts regarding the above claim, or Client(s) commit a breach of this Agreement, Attorney shall have the right to terminate his services upon giving reasonable notice to Client(s). MISCELLANEOUS: Client(s) understand, acknowledge and agree that Attorney does not guarantee the outcome or eventual result of the above claim. CLIENT'S OBLIGATION TO PROVIDE INFORMATION TO ATTORNEYS Client agrees to promptly notify attorney with respect to any information that relates to Client's claim, including changes in Client's medical treatment or employment, changes in physical condition, any new witnesses or documents or things that might be relevant to Client's claim. In addition, Client has advised Attorney that Client has not filed for bankruptcy and agrees to immediately notify attorney if Client should file for bankruptcy. In addition, Client has provided Attorney with information regarding the following potential liens that could be asserted against any recovery, and Client agrees to immediately notify Attorney if this information should change: 1. Child or spousal support obligations. 2. Social Security benefits 3. Welfare benefits of any kind. 4. Private health insurance 5. HMO benefits 6. Disability benefits 7. Workers' Compensation benefits. 8. Any other benefits paid on Client's behalf. 9. Unpaid medical bills. 10. Any other information that Client should become aware of that might represent a claim against recovery. IN WITNESS WHEREOF, the parties hereto, intending to be legally bound, have hereunto set their hands and seals of this Agreement, in execution thereof, the day and year first above written. FREEBURN & HAMILTON By: Richard E. Freeburn, Esquire 4415 North Front Street Harrisburg, PA 17110 (717) 671-1955 Witness ames Cavanaugh v Barbara Cavanaugh Individually and on behalf of Courtney Cavanaugh, their minor daughter ?651? i? 0 NOV 16 2006 COURTNEY CAVANAUGH, a minor by JAMES CAVANAUGH AND BARBARA CAVANAUGH, her natural parents and guardians, Plaintiffs V. GORDON PANILAITIS AND MARYANN BRICKER, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. OL - ?? CIVIL ACTION -LAW ORDER APPROVING MINOR'S SETTLEMENT AND NOW, THIS 2o' day of Nmr,_ s , 2006, upon review of Plaintiffs' Petition for Approval of Minor's Settlement, this Court is satisfied that the proposed settlement of this matter is reasonable and appropriate, and the same is hereby granted. Accordingly, It is hereby ordered that: 1. The settlement of this claim under the terms provided in the Petition is approved and James and Barbara Cavanaugh, parents and guardians for Courtney Cavanaugh, a minor, are authorized to sign all documents, including but not limited to the Release of Underinsured Motorist Claim, Settlement Statements, and checks and to make all payments necessary to accomplish the settlement. 2. The agreement with Freeburn & Hamilton for the payment of counsel fees and other expenses is approved, and James and Barbara Cavanaugh are authorized to pay the following counsel fees and expenses out of the fund created by the settlement: A. $1,250.00 to be paid to Freeburn 8s Hamilton pursuant to its 25 percent fee agreement; and B. Freeburn & Hamilton waives its claim for reimbursement of expenses. 3. The balance of $3,750.00 for Courtney Cavanaugh shall be deposited in a savings account to be established in the name of Courtney Cavanaugh with Sovereign Bank, Mechanicsburg, Pennsylvania, which is insured by the FDIC, provided that the amount deposited in such account shall not exceed the amount to which the account is thus insured, and that no withdrawals can be made from said account until Courtney Cavanaugh attains majority, except as authorized by a prior Order of Court. 4. A Proof of the deposit shall be promptly filed of record. 5. Upon the payment of the settlement proceeds, Freeburn & Hamilton is authorized to file a Praecipe with the Prothonotary of Cumberland County marking this matter settled and discontinued with prejudice. BY THE COURT: J. ti G IIYD n w w COURTNEY CAVANAUGH, a minor by JAMES CAVANAUGH AND BARBARA CAVANAUGH, her natural parents and guardians, Plaintiffs V. GORDON PANILAITIS AND MARYANN BRICKER, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : NO. 06-6608 Civil Term CIVIL ACTION -LAW PROOF OF DEPOSIT AND NOW, comes Freeburn & Hamilton, and files the following Proof of Deposit for Courtney Cavanaugh, pursuant to Pa. R.C.P. No. 2039(b)(2), as set forth in Exhibit "A" attached hereto. The account evidenced in Exhibit "A" is subject to a provision that no withdrawal can be made from the account until the minor attains majority, except as authorized by a prior Order of Court. Respectfully submitted, FREEBURN & HAMILTON By: -?? Richard E. Freeburn, Esquire I.D. No. 30965 4415 North Front Street Harrisburg, PA 17110 (717) 671-1955 Dated: 11/27/07 Attorney for Plaintiff 0 COURTNEY CAVANAUGH, a minor by JAMES CAVANAUGH AND BARBARA CAVANAUGH, her natural parents and guardians, Plaintiffs V. GORDON PANILAITIS AND MARYANN BRICKER, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-6608 Civil Term CIVIL ACTION - LAW COURTNEY CAVANAUGH ACCOUNT AGREEMENT By, Pennsylvania State Employees Credit Union, Harrisburg, Pennsylvania: WHEREAS, complete copy of an Order Approving Minor's Settlement has been provided to Sovereign Bank, Mechanicsburg, Pennsylvania; and, WHEREAS, the net settlement proceeds in the sum of $3,750.00 have been deposited in a bank account in the name of Courtney Cavanaugh with Sovereign Bank, Pennsylvania (hereinafter referred to as the "Courtney Cavanaugh Account"); and, WHEREAS, Sovereign Bank, Mechanicsburg, Pennsylvania is insured by the FDIC. AGREEMENT Sovereign Bank, Mechanicsburg, Pennsylvania, agrees that a hold will be placed on the Courtney Cavanaugh Account so that no transfers or withdrawals can be made from the account until Courtney Cavanaugh attains her majority, except as authorized by a prior Order of Court. ATTEST: &M-O& fitness COMMONWEALTH OF PENNSYLVANIA Notarial Seal Michelle C. Quaca, Notary Public Camp Hill Boro, Cumberland County My Commission Expires July 30, 2010 Member, Pennsylvania Association of Notaries SOVEREIGN BANK MECHANICSBURG, PENNSYLVANIA By: S C -LM ?S(O-M O N C-BIV4 Print Name and Position with Bank EXHIBIT "A" C-7