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KENNETH RANDOLPH and
VIVIAN RANDOLPH, parents and
natural guardians of
vivian Randolph and
Immanuel Randolph, minors,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. /1 0 5' ~ 19 ? 'f
v.
ROBERT GEYER and
FAY D. GEYER,
Defendants
AND NOW, this
7t/I
ORDER #lftW?, 'ftfJ
day of ~,..-_. !": l.iM', a hearing
is hereby scheduled on the Petition of Plaintiff for approval of
the minor settlement. Said hearing is scheduled for the Cumberland
county courthouse, Courtroom number
~daYOf
/!-.m.
I on the
, 199.!/.-- at..J :(J~
BY THE COURT:
, 1/"'/
';,
,
i
,
!
KENNETH RANDOLPH and
VIVIAN RANDOLPH, parents and
natural guardians of
Vivian Randolph and
Immanuel Randolph, minors,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO.
v.
.
.
ROBERT GEYER and
FAY D. GEYER,
Defendants
ORDER
AND NOW, this
day of
19 , upon the Petition of Kenneth Randolph and Vivian Randolph
and as parents and natural guardians of Vivian Randolph and
Immanuel Randolph, minors, and upon the hearing thereon, the
parties may compromise this action upon the terms of the proposed
compromise set forth in the Petition filed by Plaintiff and execute
any and all documents to effect said compromise, including but not
limited to a Release.
The balance of $4,000.00 for Vivian Randolph and $4,000.00 for
Immanuel Randolph shall be paid to said guardian to be placed in
separate insured, interest bearing accounts.
No withdrawal
therefrom can be made from their respective accounts until Vivian
Randolph, a minor, reaches majority or until Immanuel Randolph
reaches majority except as is authorized by Court Order.
Kenneth Randolph and Vivian Randolph as parents and natural
guardians of Vivian Randolph and immanuel Randolph minors, are
authorized to execute all documents necessary to effect the
resolution of this matter.
J.
,
KENNETH RANDOLPH and
VIVIAN RANDOLPH, parents and
natural guardians of
Vivian Randolph and
Immanuel Randolph, minors,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO.
v.
ROBERT GEYER and
FAY D. GEYER,
Defendants
.
.
.
.
PETITION TO COMPROMISE ACTION AND DIRECT DISTRIBUTION
1. Kenneth Randolph and Vivian Randolph are adult individuals
residing at 2735 Ritner Highway, Carlisle, Pennsylvania 17013.
2. Kenneth Randolph and Vivian Randolph are the parents and
natural guardians of Vivian Randolph, their child, who was sixteen
years old at the time of the accident and Immanuel Randolph, their
child, who was twelve years old at the time of the accident.
3. On February 20, 1993, Vivian Randolph and Immanuel
Randolph were injured when the automobile in which they were riding
was involved in an accident involving an automobile owned by Fay D.
Geyer and which was being operated by Robert Geyer.
4. Vivian Randolph and Immanuel Randolph suffered soft tissue
injuries, a copy of the medical costs are attached hereto as
Exhibit "A".
5. While Defendants and their insurer assert that they are
not liable to Plaintiffs, Defendant and their insurer is willing to
compromise this action with settlement in the amount of $4,000.00
each for any and all damages for injuries to Vivian Randolph and
Immanuel Randolph.
6. Kenneth Randolph and Vivian Randolph, as parents and
natural guardians are willing to enter into this Settlement
Agreement with Defendants and their insurer for the claims of
Vivian Randolph and Immanuel Randolph.
7, Kenneth Randolph and Vivian Randolph, as parents and
natural guardians of Vivian and Immanuel Randolph, minors, believe
that the compromise is in the best interest of the minor.
8. No guardian of the estates for Vivian Randolph or Immanuel
Randolph has been appointed and none is to be appointed.
9. Vivian Randolph and Immanuel Randolph reside with and are
maintained and supported by their parents, Kenneth Randolph and
Vivian Randolph.
10. Petitioner request the Court then approve the transfer of
said funds to the name of Vivian Randolph and Immanuel Randolph
upon their respective attainment of eighteen (18) years of age.
11. Petitioner further request that this Honorable Court
approve Kenneth Randolph and Vivian Randolph, as parents and
natural guardians, to execute the Releases necessary to resolve
this action, a copy of which is attached hereto as Exhibit "B".
WHEREFORE, Petitioner requests this Honorable Court to:
(a) Approve the compromise as stated above;
(b) To authorize the execution of any documents, including
but not limited to the Releases attached hereto to
consummate said settlement;
'tv'\ ~~
""'..tM.l,
V vian Ran 0 ph, par nt iihd
natural guardian of
Vivian Randolph and Immanuel
Randolph
(c) Direct the payment of $4,000.00 each on behalf of Vivian
Randolph and Immanuel Randolph for depositing in
restricted accounts at a bank and to authorize the
parents and natural guardians to execute any documents
necessary to consummate this settlement.
Kenneth Randolph, parent and
natural guardian of
Vivian Randolph and Immanuel
Randolph
t
VERIFICATION
We, Kenneth Randolph and Vivian Randolph, parents and natural
guardians of vivian Randolph and Immanuel Randolph, minors, have
read the foregoing Petition for Minor's Settlement and hereby
affirm that it is true and correct to the best of our personal
knowledge or information and belief. This Verification and
statement is made subject to the penalties of 18 Pa.C.S. 54904
relating to unsworn falsification to authorities. We verify that
all the statements made in the foregoing are true and correct and
that false statements may subject me to the penalties of 18 Pa.C.S.
5 4904.
Kenneth Randolph
Exhibit A
(')9/2'2/93
. .nrrriL BILL - LOSS HISTORY
F'AGE
, OF
INJURED PERSON.
POLICYHOLDER:
CONT..~CT PERSON:
TOTAL LOSS PAID:
eL,;! ~I NUMBER'
!NJURED PERSON 10:
DATE OF LOSS:
DEDUCTIBL~ APPLIED:
CO-PAYMENT AMOUNT'
9ILLEIl
AI1r
t ~~1::1 :;117
II
1)2/:1)/ 1 '~-;-
$0.1.
~,). 'e
DATE DATE
RECD PAID PROVIDER
063093 071393 BaCH CHIROPF:ACTIC CLWIC
051893 %0193 BOCH CI.IIROPR,:'CTIC CLINIC
i!lC'**l!lt 060193 BOCH CHIRO CLrr~IC
FRO,,!
THRU
PAIr
1:11'IT
0~(}.:)'13
0303?3
04029:3
'160-193
033193
0!:()'193
~!;().1)0
a49.00
200
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09 /:'~/93
MEDICAL BILL - LOSS HISTORY
PAGE
i OF
INJURED PEF:SON:
POLICYHOLDER:
CONT ,'\CT PERSON:
TOTAL LOSS PAID:
'A/JDOLPH. VI'/IAt
RANDOLPH, KI:.I
AS ~'TI\ ~'"r.TO
SI.n8.80
CLA 1M NutlBER:
INJURED PERSON ID:
DATE OF LOSS:
DEDUCTIBLE APPLIED:
CO-PAYMENT AMOUNT:
155121817:
03
02/20/199::
1>0.0(
$O.I~(
DATE DATE
F~ECD PAID F ROV DEF:
0630~3 1~71393 BaCH CHIROPRAC7!C CL NIC
051893 060193 BOCH CHIF:OPRACTIC CL IHC
041393 '~42093 BOCH CHIROPR,;CTIC CL i'lIC
BILLED
FROM THRU AMT
051093 ,,61193 578.00
040293 050393 650.00
022693 ',33193 1285.00
F"~IID
AMT
482.:
1:'......., ":
.J.........~
934. ~
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Exhibit B
RELEASE OF CLAIMS
For and in consideration of the payment to us of the sum of
Four Thousand Dollars ($4,000.00), we, Kenneth Randolph and Vivian
Randolph individually and as parents and natural guardians of
Vivian Randolph, a minor ("Releasers"), do hereby release and
forever discharge Robert Geyer, Fay D. Geyer, their insurers and
representatives, of and from any and all actions, causes of action,
claims demands, damages, costs, loss of services, expenses,
compensation, consequential damage, or any other thing whatsoever
on account of or in any way growing out of, any and all known and
unknown personal injuries and debts and property damage resulting
or to result from an accident that occurred on or about the 20th
day of February, 1993.
We hereby acknowledge and assume all risk, chance, or hazard
that the said injuries or damage may be or become permanent,
progressive, greater, or more extensive than is now known,
anticipated, or expected. No promise or inducement which is not
herein expressed has been made to us and in executing this Release
we do not rely upon any statement or representation made by any
person, firm, or corporation hereby released or any agent,
physician, doctor or any other person representing them or any of
them concerning the nature, extent, or duration of said damages or
losses or the legal liability therefor.
We understand that this settlement is the compromise ot a
disputed claim and that the payment is not to be construed as an
admission of liability on the part of the persons, firms and
corporation hereby released by whom liability is expressly denied.
This Release contains the entire agreement between the parties
hereto and the terms of this Release are contractual and not a mere
recital.
In further consideration of the above payment, we tor
ourselves, our heirs, next of kin, executors, administrators,
successors and assigns covenant and agree to indemnify and hold
harmless Robert Geyer, Fay D. Geyer and West American Insurance
Company for all claims, demands and suits for damages, costs, loss
of services, expenses, or compensation which we or our heirs,
insurers, next of kin, executors, administrators, successors or
assigns have or may have on account of or in any way growing out of
the injuries received in this incident.
We certify that we are over eighteen (18) years of age, that
we are the parents and natural guardians of Vivian Randolph, a
minor and we further state that we have carefully read the
foregoing Release and know the contents thereof and we signed the
same as our own free acts and intending to be legally bound
thereby.
8
IN WITNESS WHEREOF, wo have hereunto set our hands and seals
this
WITNESSETH:
day of
, 1993.
J~A -:z LJ} J) (SEAL)
Kenneth Ra~/parent and
natural guardian of Vivian Randolph
and Immanuel Randolph
~~~1~~i and (SEAL)
natural guardian of Vivian Randolph
and Immanuel Randolph
Sworn to and subscribed
before me this Q 0
day of \)r~
1993. t!'
~Q..,' O'l"\ K CO/}-?.f.f(
NOTARY PUBLIC
NO I !.pIM SfAl
S!L\RON Ii CA'.iSlll. tllll:Y P~blic
C~;;,,:;~.Cut:ll):nrlr.a C1JtJnlV
My Con;mlss,on E>plros /.pr,12I, 1997
My commission expires:
9
RELEASE OF CLAIMS
For and in consideration of the payment to us of the sum of
Four Thousand Dollars ($4,000.00), we, Kenneth Randolph and Vivian
Randolph individually and as parents and natural guardians of
Immanuel Randolph, a minor ("Releasers"), do hereby release and
forever discharge Robert Geyer, Fay D. Geyer, their insurers and
representatives, of and from any and all actions, causes of action,
claims demands, damages, costs, loss of services, expenses,
compensation, consequential damage, or any other thing whatsoever
on account of or in any way growing out of, any and all known and
unknown personal injuries and debts and property damage resulting
or to result from an accident that occurred on or about the 20th
day of February, 1993.
We hereby acknowledge and assume all risk, chance, or hazard
that the said injuries or damage may be or become permanent,
progressive, greater, or more extensive than is now known,
anticipated, or expected. No promise or inducement which is not
herein expressed has been made to us and in executing this Release
we do not rely upon any statement or representation made by any
person, firm, or corporation hereby released or any agent,
physician, doctor or any other person representing them or any of
them concerning the nature, extent, or duration of said damages or
losses or the legal liability therefor.
10
We understand that this settlement is the compromise of a
disputed claim and that the payment is not to be construed as an
admission of liability on the part of the persons, firms and
corporation hereby released by whom liability is expressly denied.
This Release contains the entire agreement between the parties
hereto and the terms of this Release are contractual and not a mere
recital.
In further consideration of the above payment, we for
ourselves, our heirs, next of kin, executors, administrators,
successors and assigns covenant and agree to indemnify and hold
harmless Robert Geyer, Fay D. Geyer and West American Insurance
Company for all claims, demands and suits for damages, costs, loss
of services, expenses, or compensation which we or our heirs,
insurers, next of kin, executors, administrators, successors or
assigns have or may have on account of or in any way growing out of
the injuries received in this incident.
We certify that we are over eighteen (18) years of age, that
we are the parents and natural guardians of Vivian Randolph, a
minor and we further state that we have carefully read the
foregoing Release and know the contents thereof and we signed the
same as our own free acts and intending to be legally bound
thereby.
11
IN WITNESS WHEREOF, we have hereunto set our hands and seals
this
WITNESSETH:
day of
, 1993.
)(~_ /2~~) (SEAL)
genneth'Ran 0 h,lparent and
natural guardian of Vivian Randolph
and Immanuel Randolph
Y.).~cu.A- ~lVl-' /j"L. (SEAL)
Vivian Randolph, ~ and
natural guardian of Vivian Randolph
and Immanuel Randolph
Sworn to and subscribed
before me this dC)
day of 4'''''''' ,
j;.
Ct5l,...... ~C"a1.,")/IO
N TARY PUBLIC '
My commission expires:
12
MAR '7 19~...-
..
KENNETH RANDOLPH and
VIVIAN RANDOLPH, parents and
natural guardians of
Vivian Randolph and
Immanuel Randolph, minors,
Plaintiffs
.
.
.
.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 1/ 0 S C('v~L I qiil/-
:
.
.
:
v.
.
.
ROBERT GEYER and
FAY D. GEYER,
Defendants
.
.
ORDER
0/1 cw:J... I q 'N,
day of DQ{,9""~r, ~, a hearing
AND NOW, this
7 :ti\..
is hereby scheduled on the Petition of Plaintiff for approval of
the minor settlement. Said hearing is scheduled for the Cumberland
.:lS-u...
L.m.
day of
'l4J 0Ae,h.,
,
I
, 199 Lf
, on the
at 3: 00
County Courthouse, Courtroom number
BY THE COURT:
1<5 I 7J.:v..~U. C ..xlA.t.~. .
TRUE COpy FROM RECORD
In Trstim~ny v,flrcof. I hN~ unlO sat my hand
and the seal of said Courl ijl Carlisle, Pa.
This ......8.,~.. day of...7.:r.t~~ 19,~,l:I.
.............4ir~p;f~t:'.._.....
KENNETH RANDOLPH and
VIVIAN RANDOLPH, parents and
natural guardians of
Vivian Randolph and
Immanuel Randolph, minors,
Plaintiffs
.
.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No.qtf-1I0~- tUrJ. T~
.
.
.
.
v.
.
.
ROBERT GEYER and
FAY D. GEYER,
Defendants
.
.
.
.
.
.
~ NOW,
19~, upon
this
t ~RDER
~ S day of
~
the Petition of Kenneth Randolph and Vivian Randolph
and as parents and natural guardians of Vivian Randolph and
Immanuel Randolph, minors, and upon the hearing thereon, the
parties may compromise this action upon the terms of the proposed
compromise set forth in the Petition filed by. Plaintiff and execute
any and all documents to effect said compromise, including but not
limited to a Release.
The balance of $4,000.00 for Vivian Randolph and $4,00Q.00 for
Immanuel Randolph shall be paid to said guardian to be placed in
separate insured, interest bearing accounts.
No withdrawal
therefrom can be made from their respective accounts until Vivian
Randolph, a minor, reaches majority or until Immanuel Randolph
reaches majority except as is authorized by Court Order.
Kenneth Randolph and Vivian Randolph as parents and natural
guardians of Vivian Randolph and immanuel Randolph minors, are
authorized to execute all documents necessary to effect the
resolution of this matter.
IkLuA b ftu/
I I J.
,
; ',.', " , '~,~l...~__; ;'; ,I,':'.)
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S~I ~d L'l"l q '\'If
KENNETH RANDOLPH and
VIVIAN RANDOLPH, parents and
natural guardians of
Vivian Randolph and
Immanuel Randolph, minors,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO.
.
.
.
.
v.
ROBERT GEYER and
FAY D. GEYER,
Defendants
.
.
PBTITION TO COMPROMISB ACTION AND DIRBCT DISTRIBUTION
1. Kenneth Randolph and vivian Randolph are adult individuals
residing at 2735 Ritner Highway, Carlisle, pennsylvania 17013.
2. Kenneth Randolph and Vivian Randolph are the parents and
natural guardians of Vivian Randolph, their child, who was sixteen
years old at the time of the accident and Immanuel Randolph, their
child, who was twelve years old at the time of the accident.
3. On February 20, 1993, Vivian Randolph and Immanuel
Randolph were injured when the automobile in which they were riding
was involved in an accident involving an automobile owned bX Fay D.
Geyer and which was being operated by Robert Geyer.
4. Vivian Randolph and Immanuel Randolph suffered soft tissue
injuries, a copy of the medical costs are attached hereto as
Exhibit "A".
5. While Defendants and their insurer assert that they are
not liable to Plaintiffs, Defendant and their insurer is willing to
compromise this action with settlement in the amount of $4,000.00
each for any and all damages for injuries to Vivian Randolph and
Immanuel Randolph.
6. Kenneth Randolph and Vivian Randolph, as parents and
natural guardians are willing to enter into this Settlement
Agreement with Defendants and their insurer for the claims of
Vivian Randolph and Immanuel Randolph.
7. Kenneth Randolph and Vivian Randolph, as parents and
natural guardians of Vivian and Immanuel Randolph, minors, believe
that the compromise is in the best interest of the minor.
8. No guardian of the estates for Vivian Randolph or Immanuel
Randolph has been appointed and none is to be appointed.
9. Vivian Randolph and Immanuel Randolph reside with and are
maintained and supported by their parents, Kenneth Randolph and
Vivian Randolph.
10. Petitioner request the Court then approve the transfer of
said funds to the name of Vivian Randolph and Immanuel Randolph
upon their respective attainment of eighteen (18) years of age.
11. Petitioner further request that this Honorable Court
approve Kenneth Randolph and Vivian Randolph, as parents and
natural guardians, to execute the Releases necessary to resolve
this action, a copy of which is attached hereto as Exhibit "B".
WHEREFORE, Petitioner requests this Honorable Court to:
(a) Approve the compromise as stated above;
(b) To authorize the execution of any documents, including
but not limited to the Releases attached hereto to
consummate said settlement;
(c) Direct the payment of $4,000.00 each on behalf of Vivian
Randolph and Immanuel Randolph for depositing in
restricted accounts at a bank and to authorize the
parents and natural guardians to execute any documents
necessary to consummate this settlement.
J!.__ .?. _. -LJL
Kenneth-Randolph, parent and
natural guardian of
Vivian Randolph and Immanuel
Randolph
'tv" ~ ~~
V v1~~an flph, par nt ~ihd
natural guardian of
Vivian Randolph and Immanuel
Randolph
VBRIPICATION
We, Kenneth Randolph and Vivian Randolph, parents and natural
guardians of Vivian Randolph and Immanuel Randolph, minors, have
read the foregoing Petition for Minor's Settlement and hereby
affirm that it is true and correct to the best of our personal
knowledge or information and belief.
This Verification and
statement is made subject to the penalties of 18 Pa.C.S. S4904
relating to unsworn falsification to authorities. We verify that
all the statements made in the foregoing are true and correct and
that false statements may subject me to the penalties of 18 Pa.C.S.
S 4904.
I<~~ ~4
Kenneth Rand ph
,
--- "
/.., ,'. " "";,,J;. iJ '.
V v an Randolph
Exhibit A
. ----
. , .' .... ,
09/20/93
nT~;L BILL - LOSS HISTORY
PAGE I OF
INJUF:ED PERSON,
POLICYHOLDER:
CONTACT PERSON:
TOTAL LOSS PAID:
CLAIM NUMBER:
I~JURED PERSON ID:
DATE OF LOSS:
DEDUCTIBLE APPLIED:
CO-PAYMENT AMOUNT:
15:'12181,
II
02n0/19~
$0.(
$0. E
DATE DATE
RECD PAID PROVIDER
FROM THRU
050693 060493
030393 033193
040293 050493
BILLED
AMT
F'AII
~li1T
063093 071393 BOCH CHIROPRACTIC CLINIC
051893 060193 BOCH CHIROPRACTIC CLINIC
****MM 060193 BOCH CHIRO CLINIC
250.00
849.00
200.
628.
7e;.,
.-.
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\1;;;':::;; -:
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09/::'Z'/93
MEDICAL B!LL - LOSS HISTORY
PAGE 1 OF
INJURED PERSQi4:
POLICYHOLDER:
CONTACT F'ERSOII:
TOTAL LOSS P;,ID:
'All 'OLF'H. VIVIAI
RANDOLPH,
AS ~'T . ~., 0
$1.938.80
CLAIM NUMBER:
INJURED PERSON ID:
DATE OF LOSS:
DEDUCTIBLE APPLIED:
CO-PAYME~T AMOUNT:
BILLED
AMT
155121817:
03
02120/199~
$0.0(
$0.01;
DATE DATE
RECD PAID PROVIDER
063093 071393 BOCH CHIROPRACTIC CLINIC
051893 060193 BOCH CHIROPRACTIC CLINIC
041393 042093 BOCH CHIROPRACTIC CLINIC
FROM THRU
P,;ID
AMT
051093 061193
040293 050393
022693 033193
578.00
650.00
1285.00
482.:
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Exhibit B
RBLBASB OP CLAIMS
For and in consideration of the payment to us of the sum of
Four Thousand Dollars ($4,000.00), we, Kenneth Randolph and Vivian
Randolph individually and as parents and natural guardians of
Vivian Randolph, a minor ("Releasers"), do hereby release and
forever discharge Robert Geyer, Fay D. Geyer, their insurers and
representatives, of and from any and all actions, causes of action,
claims demands, damages, costs, loss of services, expenses,
compensation, consequential damage, or any other thing whatsoever
on account of or in any way growing out of, any and all known and
unknown personal injuries and debts and property damage resulting
or to result from an accident that occurred on or about the 20th
day of February, 1993.
We hereby acknowledge and assume all risk, chance, or hazard
that the said injuries or damage may be or become permanent,
progressive, greater, or more extensive than is now. known,
anticipated, or expected. No promise or inducement which is not
herein expressed has been made to us and in executing this Release
we do not rely upon any statement or representation made by any
person, firm, or corporation hereby released or any agent,
physician, doctor or any other person representing them or any of
them concerning the nature, extent, or duration of said damages or
losses or the legal liability therefor.
We understand that this settlement is the compromise of a
disputed claim and that the payment is not to be construed as an
admission of liability on the part of the persons, firms and
corporation hereby released by whom liability is expressly denied.
This Release contains the entire agreement between the parties
hereto and the terms of this Release are contractual and not a mere
recital.
In further consideration of the above payment, we for
ourselves, our heirs, next of kin, executors, administrators,
successors and assigns covenant and agree to indemnify and hold
harmless Robert Geyer, Fay D. Geyer and West American Insurance
Company for all claims, demands and suits for damages, costs, loss
of services, expenses, or compensation which we or our heirs,
insurers, next of kin, executors, administrators, successors or
assigns have or may have on account of or in any way growing out of
the injuries received in this incident.
We certify that we are over eighteen (18) years of ag~, that
we are the parents and natural guardians of Vivian Randolph, a
minor and we further state that we have carefully read the
foregoing Release and know the contents thereof and we signed the
same as our own free acts and intending to be legally bound
thereby.
8
this
IN WITNESS WHEREOF, we have hereunto set our hands and seals
day of
WITNESSETH:
Sworn to and subscribed
before
oC:
me this
J(l~
day of
,
1993.
~/' ~;l /,
"l (\ \ ~"\ "- C{r ?;H ((
NOTARY PUBLIC
My commission expires:
, 1993.
J~_ (J LlJ I-. (SEAL)
Kenneth ~parent and
natural guardian of Vivian Randolph
and Immanuel Randolph
~~~t"~~~ and (SEAL)
natural guardian of Vivian Randolph
and Immanuel Randolph
MJTtFIAl SCAl
E'l~!l[!N Ii CI.SSlll" 1I)',;:v :>~~:;c
C.";,:", Cu.-,j!y;t;.u Cr';.'y
My CJ~";';s;or, ElPl,cs'April2l, 1937
9
RBLBASE OP CLAIMS
For and in consideration of the payment to us of the sum of
Four Thousand Dollars ($4,000.00), we, Kenneth Randolph and Vivian
Randolph individually and as parents and natural guardians of
Immanuel Randolph, a minor ("Releasers"), do hereby release and
forever discharge Robert Geyer, Fay D. Geyer, their insurers and
representatives, of and from any and all actions, causes of action,
claims demands, damages, costs, loss of services, expenses,
compensation, consequential damage, or any other thing whatsoever
on account of or in any way growing out of, any and all known and
unknown personal injuries and debts and property damage resulting
or to result from an accident that occurred on or about the 20th
day of February, 1993.
We hereby acknowledge and assume all risk, chance, or hazard
that the said injuries or damage may be or become permanent,
progressive, greater, or more extensive than is now known,
anticipated, or expected. No promise or inducement which, is not
herein expressed has bAen made to us and in executing this Release
we do not rely upon any statement or representation made by any
person, firm, or corporation hereby released or any agent,
physician, doctor or any other person representing them or any of
them concerning the nature, extent, or duration of said damages or
losses or the legal liability therefor.
10
We understand that this settlement is the compromise of a
disputed claim and that the payment is not to be construed as an
admission of liability on the part of the persons, firms and
corporation hereby released by whom liability is expressly denied.
This Release contains the entire agreement between the parties
hereto and the terms of this Release are contractual and not a mere
recital.
In further consideration of the above payment, we for
ourselves, our heirs, next of kin, executors, administrators,
successors and assigns covenant and agree to indemnify and hold
harmless Robert Geyer, Fay D. Geyer and West American Insurance
Company for all claims, demands and suits for damages, costs, loss
of services, expenses, or compensation which we or our heirs,
insurers, next of kin, executors, administrators, successors or
assigns have or may have on account of or in any way growing out of
the injuries received in this incident.
We certify that we are over eighteen (18) years of age, that
we are the parents and natural guardians of Vivian Randolph, a
minor and we further state that we have carefully read the
foregoing Release and know the contents thereof and we signed the
same as our own free acts and intending to be legally bound
thereby.
11
.
IN WITNESS WHEREOF, we have hereunto set our hands and seals
this
WITNESSETH:
day of
, 1993.
}((- /2~~ 1 (SEAL)
Kenneth'Ran 0 h,lparent and
natural guardian of Vivian Randolph
and Immanuel Randolph
Y.J.v'tA.V- ~a"" /- J -J.... (SEAL)
Vivian Randolph, ~ and
natural guardian of Vivian Randolph
and Immanuel Randolph
Sworn to and subscribed
before me this de:-
day of ~r\ 1~
~'93.
\ -
"ll 0(, (J
--LJI Irl "t """ ~La 1 )/ fI .'
NOTARY PUBLIC
My commission expires:
12