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DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JENELDA :
PUZZO, in their own right,
Plaintiffs
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
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v.
MICHELLE ASKINS, CIVIL ACTION - LAW
Defendant NO. 94-1882 CIVIL TERM
IN RE: MINOR'S SETTLEMENT
BEFORE SHEELY. P.J.
MEMORANDUM OPINION AND ORDER OF COURT
A hearing was held today on a petition of the
Plaintiffs to approve a settlement with ohio Casualty Company,
their underinsurance carrier. I had previously approved a
settlement with the Defendant's insurance company, and at the
hearing today I heard the testimony of Mrs. Puzzo who indicated
that Debra has not had any problems since we had our original
hearing in May of 1994 as a result of the injuries in this case.
They have now reached an agreement with Ohio Casualty
Company to settle the underinsurance claim, and the agreement is
that a lump sum payment of $5,000.00 will be payable to the
parents, and from that sum of $5,000.00 I will authorize $200.00
of that to be paid to counsel for the Plaintiffs for his
appearance in court today and for preparation of the petition.
The balance of $4,800.00 shall be deposited in an
existing, restricted account that was opened after the hearing
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in May of 1994, and this money shall be subject to the same
terms and conditions as previously set forth.
In addition Ohio Casualty will make four payments of
$5,146.34 commencing August 5th, 2004, and ending August 5th,
2007. Mrs. Puzzo indicates that this has been discussed and is
agreeable to she and her husband, and, therefore, I will sign
the order authorizing the settlement of this action with their
underinsurance carrier for the terms above set forth.
It was brought to my attention also that the above
four payments shall be paid by the Ohio Life Insurance Company.
By the Court,
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Paul L. Zeigler, Esquire _ c...,..~ ",....,::.cc<l '11 ;;1.'1/ qs.
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JUl 27 9 S4 ,iH '95
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DBBRA PUZZO, a minor, by
DANXBL A. puzzo and JENBLDA
PUZZO, her parents and
natural guardians, and
DANXBL A. PUZZO and JENBLDA
PUZZO, in their own right,
Plaintitrs
v.
MICHBLLB ASKINS,
Defendants
AND NOW, this ,,--'#lay of
hereby ORDERED that a hearing
approval of the within Petition
Settlement.
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IN THE COURT OP COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CXVIL ACTXON - LAW
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ORDER
~'L
, 1994, it is
be held for consideration and
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Courtroom No.
Said hearing shall be held
, 19~at J: (JO
~, Cumberland County
for Court Approval of a Minor's
on the ~ -l-tlJay of
o'clock L.M. in
Pennsylvania.
Courthouse,
Carlisle,
BY THE COURT:
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From the desk of
IlAROl.D E. SllEELY
President Judge
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PAUL L. ZEIGLER
ATTORNEY AT LAW
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ZEltlLBR & ZIMMERMAN PC
355 N. 21ST SYnEET, SUITE 304 ' ,
P.O, sox 1010
CAMP HILL. PA 17011.3707
TELEPHONE
(7171731.14..
FAX
17171731.1485
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DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JENELDA
PUZZO, in their own right,
Plaintiffs
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
MICHELLE ASKINS, CIVIL ACTION - LAW
Defendant NO. 94-1882 CIVIL TERM
IN RE: MINOR'S SETTLEMENT
BEFORE SHEELY. P.J.
MEMORANDUM OPINION AND ORDER OF COURT
A hearing was held today on the petition to approve
the compromise settlement in the above-captioned case. The
Court is satisfied from hearing the testimony of the minor's
mother that apparently she has recovered from the injuries
sustained in this accident except the mother did indicate that
there may have to be something done with some bottom teeth, and
that will have to be resolved in the future.
The petition alleged that the maximum limit of
coverage of the Defendant in this case was $25,000.00, and the
Defendant's insurance company has agreed to pay that sum in
settlement of the above claim.
At the hearing today we heard that the Plaintiffs' own
insurance carrier, Ohio Casualty, apparently is proposing to pay
the Plaintiff an additional $15,000.00 from the underinsurance
coverage on their policy. That has not been made definite at
this time, but in the future Ohio Casualty will be pay that sum.
The Court will sign a release accordingly, and the
Court would direct that should that be the case, that the
Puzzo'S, as natural guardians of Debra, are authorized to
receive that money provided that it is also deposited in an
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account in the name of Debra in the same manner in which the
balance of the proceeds in this particular case are to be
disclosed.
Now, in that regard, I direct that the Plaintiffs
forward to me or their counsel within fourteen days after the
account is opened for the net proceeds a copy of the account as
opened. With that the Court will sign the order requested in
this particular case.
By the Court,
~ - 17-
Date
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HarOld E. Sheely, P.J.
Paul L. Zeigler, Esquire
For the Plaintiffs
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HAy 1lJ 1995
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DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
naturalguardmn~ and
DANIEL A. PUZZO and JENELDA
PUZZO, In their own right,
Plaintiffs
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
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: CIVIL ACTION - LA W
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: No. 94.1882 Civil Term
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v.
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MICHELLE ASKINS,
:
Defendants
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ORDER
AND NOW, this Mndy of )J}A Y
, 1995, 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 ~ on the ,)...5 t:h day of _ LZ~ pI , ~El!at / :j() . L.m.
BY THE COURT:
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DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardIans, and
DANIEL A. PUZZO and JENELDA
PUZZO, In their own right,
Plaintiffs
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
.
.
: CIVIL ACTION - LA W
.
.
: No. 94- 7882 Civil Term
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:
v.
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:
MICHELLE ASKINS,
.
.
Defendants
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, ,HORDER . /
AND NOW, this 7.--<; day of -~:2J ' , , upon the
Petition of Daniel Puzzo and Jenelda Puzzo and as parents and natu I guardians of
Debra Puzzo, a minor, and upon the hearing thereon, the parties may compromise this
action upon the terms of the proposed comprise set forth In the Petition flied by
Plaintiff and execute any and all documents to effect said compromise, Including but
not limited to a Release.
The amount of $70,000.00 Is approved for payment for a structured
settlement payable to Debra Puzzo upon her reaching majority. The balance of
$5,000.00 shall be paid to said guardian to be placed In separate Insured, Interest
bearing accounts. No withdrawal therefrom can be made from the account until Debra
Puzzo, a minor, reaches majority except as Is authorized by Court Order.
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Dsnlel Puzzo snd Jenelds Puzzo, ss psrents snd nstursl gusrdlsns of
Debrs Puzzo, B minor, Bre suthorlzed to execute BI/ documents necessBry to effect the
resolution of thIs mBtter.
J.
Defendents
:
,
DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parants and
natural guardians, and
DANIEL A. PUZZO and JENELDA
PUZZO, In their own right,
PlaIntiffs
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
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: CIVIL ACTION. LA W
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: No. 94.1882 Civil Term
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v.
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MICHELLE ASKINS,
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PETITION TO COMPROMISE
ACTION AND DIRECT DISTRIBUTION
1. Daniel Puzzo and Jenelde Puzzo are adult Indlvlduels residing at
336 Locust Point Roed, Mechenicsburg, Pennsylvenia 17055.
2. Daniel Puzzo and Jenelda Puzzo are the parents and natural guardians
of Debra Puzzo, their child, who was six years old at the time of the accident.
3. On May 6, 1993, Debra Puzzo was Injured when struck by an
automobile.
4. Debra Puzzo suffered a fractured left femur and head Injuries, a copy
of the medical costs are attached hereto as Exhibit "A".
5. Ohio Casualty Insurance Company, the uninsured/underinsured
motorist insurer of Plaintiff's vehicle, is willing to compromise this action with
settlement in the amount of $15,000.00, being the limits of the
uninsured/underinsured motorists coverage.
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6. No guardian of tha estate for Dabra Puzzo has bean appointad and
none Is to be appoInted.
7. Debra Puzzo resIdes with and is maIntained and supported by her
parents, Daniel Puzzo and Jenelda Puzzo.
8. Ohio Casualty proposes payment of $10,000.00 for a structured
settlement, providIng benefits, as set forth in Exhibit "B", payable to Debra Puzzo
upon the age of majority. The balance of $5,000.00 shall be payable into an insured
bearing account restricted from withdrawal until Debra Puzzo reaches the age of
majority.
9. Petitioner requests the Court then approve the transfer of said funds
to the name of Debra Puzzo upon her attainment of eighteen (18) years of age.
10. Petitioner further requests that this Honorable Court approve Daniel
Puzzo and Jenelda Puzzo, as parents and natural guardians, to execute the Release
necessary to resolve this action, a copy of which is attached hereto a Exhibit "CWo
WHEREFORE, Petition 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 Release attached hereto to consummate said
settlement;
(c) Direct the payment of $10,000.00 for a structured settlement
payable to Debra Puzzo at the age of majority; and
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(d) Direct the pByment of the billBnce of 16,000.00 on behBIf of
DebrB Puzzo for depositIng in restricted Bccounts Bt B bBnk Bnd to
Buthorize the pBrBnts Bnd nBturBI gUBrdiBns to execute Bny
documBnts nBcessBry to consummBte thIs settlement.
DouglBS B. MBrcello, Esquire
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College of t-Jedicine . UniversilY Hospital
The Millo'l S. Hershey Medical Cenler
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The attachec claim repres~nts charges incurred by your insured
for ser~ic9s arisinq as a result of his/her i~volvement in an
auto accident.
According to the Board of Directors, Pennsylvania Trauma System
Founda~ion, effective October 1, 1988, University Hospital, The
Milton S. Hershey Medical Center, the Penn State University,
received acc=editation as a Reqional Resource Trauma Center,
Level I.
In accordance with that accreditation, charqes tor acute care
t=eat~ent, services for lite t~reateninq or urqent injuries
rendered at this tacility are to be paid at the usual and
customary rate not subject to the 110% Medicare-based
rei~ursement allowances as specitied under Act 6, effective
April IS, 1990.
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If you have ~~t.QtlsUPzo:; oncerns
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FEINERHAN GROUP
POBOX 2679
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PA 17105
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LIFE UON
UNIVERSrrY HOSPITAL
mE MILTON S. HERSHEY MEDICAL CENmIl
mE PENNSYLVANIA STATE UNIVERSnY
HERSHEY, PENNSYLVANIA 17033
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MEDICAL NECESSITY Bn.LING DOCUMENTATION
TO BE COMPLETED BY REFERRING PHYSICIAN
PATIENl'NAME:_P.:J'2..-z.q bl'V'lrc... FLI01ru:S3~ 05:0. DATE OF SERVICE: ~-~~.",
PATIENl'AODRESS: j~b Ur.tJ&1- ~"I'II- Rd, DlAONOSlS:Jto. ste~
rneC~c:..t\iCS~ nos~ '"''[AD.. ~"""ff./'1c)e FI.
REASON FOR AEROMEDICAL FUOIIT REQUEST (Che~tor approprialelClSDn): ~;
,~,-~....-,,~Aio nm..lsoa crIlicaUlClorln ~ paIicn~al1llYivaJ.; The ~.I;'M!CJYica aDd. rapidlrlllSpDlfprovidod.b)' 1;Il~~1!! -:--ol'~'~i
to ensuring the palien.'s vlabUil)', ' , . .
_ B. Dunlion 01 ground ltInSpon would be excessive and po.enliaUy detrimcntallO the palienL Inlensive or coronll)' core unit
capabllll)' rcquiml lor rranspon.
_ C. Weather, environmenlal or road conditions render the patienl inaccessible '0 ground ambulance setvlcc.
_ D. Specialized setvices we.. nOI available lor ground cranspon.
TYPE OF AEROMEDICAL MISSION (Check appropriale leller (s)):
_ A. Ac.idenl, mOlor vehi.le
_ B, Accldenl. work
_ C. Accidenl, nol work or mOlor vehi.le
_ D, Medi.a1emergen.y, no' ac.idenl
_ E. Transler, special or lenill)'.are la.ml)'
physl.ian oRlered or lamily requcsted
_ F, Transler, need lor npid and spe.ialized heallh .are when
health .are instiNtion localed nC41CStlO the palleftl is nOI
equipped '0 provide lrClanent or expertise ol.are
UNIVERSITY HOSPITAL SERVICES WERE SELECTED FOR: (Che.k os many os appli,"ble.)
AVlilabilil)' 01 heli,opler setvice? _NO _YES Comment on setvi.e
Relemllo physi.ian setvi.e? _NO _YES Whal physi.ian?
Relemllo tenill)' services C..g....th lab)? --=-.NO _YES Whi.h service?
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. Rel.rring Physi.ian SiJII lor Transler Pt.
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REFERRING PHYSitiAN (if appUoable):
PHONEtAC)
WIQlE copy.lNSlIRANa CDMPA/IY YEU.OW COPY-HOSPITAL BIIJJNO '!IlK COPY-IIEIJCOPTEll SEIlYla5 COUl CQPY.RE1ElWIIO PllYSICAN
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. NOTICE:rOINSURANCECOMPANIES: Inorderto expedite Ille processlnil'ollnsurance.clalms the Med'rcal '
. Center ~as- adopted a standard form which will be substlMed for the hospital and doctor's reports normally '"
.furnlsh~~,by the Insu!ance companies; .,'
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Insurance Company
Address of Ins. Co.
Name of Employer
Address- of Employer
Name of Policy Holder
Name of Patient
, Address of Patient' '
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. MlSING OUT OF 'AnENTS EMPLOY...IHn Y" C No 0 1'RIGHAHCV7 YES 0 NO C .
Policy/Group No.
Phone No.
Phone No.
.' Social Securily No.
Date. of Birth
oneill tC)SM'AL COVERAGE; YES 0 NO 0 (It V... Name" Camet.
DATE ADMITTED
TIME ADMITTED
DATE DISCHARGED
TIME DISCHARGED
DIAGNOSIS FROM RECORDS (II Injury, give dale and placl of ICCldenl)
ANESTHESIA UNITS BREAKDOWN
_ BASIC
_ TIME (_ HRS. _ MINS.)
OPERATIONS OR OBSTETRIC
_AGE _ YRS.
PHYS, STATUS NO,
_ OTHER (SpIcily on Claim)
_ TOTAL UNITS 4>> .
.JUN 10 ~
HOSPITAL
MOST COMMON
SEMIPRIVATE
DAILY RATE s......,.
The Millon S, Hershey Medical Center
,~
ADDRESS
P,O. Box 853
Hershey, PA 17033
L H M AI< N
SEe AlTACHED ITEMIZED BILLS
. "
...
TOTAL HOSPITAL CHARGES $
TOTAL PHYSICIAN(S) CHARGES $
PAYMENTS/CREDITS $
///k"7
BALANCE. DUE$ ~";""~'_~
AUTHORIZATION TO RELEASE-INFORMATION: I hereby authorize, the above-named hospital to release
such Information as Is required to complete this form or Is otherwis&, required: by Ih& Insurance' -
Company/Em~oye[~nsura'nClJ Department to process"this-clalm_ ' 1
Date' 5' - (,.. ~ ''7 ., Patient'$': Slg~ature' ,';
. ASSIGNMENT OF INSURANCE BENEFITS:: I hereby authorize 'payment rectlyto the abov&name It ~
" all.benefits.payable,to me under the-terms.of my insurancE!' policies both: with respect to hospital. and/or 'j
..':. physiciarr' . services with thB'understandlng that aref.und will b&made for. any over.p~yment less outst~dlng:: J
:, . balanc~s~ (The h?spital acts as a collecting agent for !h!: HosPital'~the physl~lan S' fee)A'\ ,....:: j"
.~ .;~-:~~~t,:" ,..f:_~~!'5~ ,'_.... Insu~~~~.~!~~.~~&:,' ~'?'~~.CI~ ,?,CYlprffr.;"",,-..,...:
.:: Fonrrcompleted::and'sent'tlT ,'..... ..' 'i'-~"., '. ,.. . ..-,... . D'at& . '. ..'
~~?~~. ~::~..~: . '~':.l:.;.'~::':: ::.~.~ '.9. . .. .r':'; 7- ;' I.~.;o.; ~~~~;,"~'.:-:;': - ~-:..:-,,-:- '~.' .... : ~':'~: .: . ", :'"'~"_./~~i:;t --:g:~-:.:
. .. . OUFfINTERNALREVENUESERVICEIDEN!IFlCATlONNUMBEFfIS2:J:.70944-11:' =..., ..... "
ATTENDING PHYSICIAN'S NAME
NATURE,
QAllU'/I'OUCY -.-aft CIIlT1n:ATUUMClIINlI-....
CC DT 05/06/~3 I DPDOZZ50654
011105/06/93"'- i~"o-;-iifi'9M
. *,.." .....
CUJr.iFbA~' . r'
- . ..
;..> ,
. .,'
o
.
SERVICES
. INPATIENT
~N4DADCMII OfIINIUMD
DANIEL A PUZZO,
~~6 LOCUST POINT
HECHANICSaUR G
ROAD
PA 17055
lW.ATlClH TO PAT1IH1'
FA THER
MAL Q.AlM TO
IClC&AL IICURIT'Y HUIlIIIII
999-99-9999
FE INERMAN GROUP
POBOX 2679
HARRISBURG
PA 17105
.. .
..
~'"
.!'~~'
c.AN DA~
06/01/93
P'IIUOO COYIMD IY tHIS Q...MI
05/06/93
IHIURAHC:I ~N4Y HAMI
05/11/93
OHIO CASUALTY INSURANCE
OROuP P'QUCY HOLDIlA
AUTO INS
'ATlEH'T NAWI. ACCOUNT HUWIII\
pur'ii:r.' DEBRA'" L~"~~o;.,.;;J:.c~,;,:.. OS7Z03r-3126'
j'I'}lIAINSUAAHCEINDICATlDIYHOI,rrALAICOROS ItEL.lTICHTO'TIHT IHSUMHClCAIUU."
'W401'INSU"ID I A f
lONE . I I
I .
21.'01 FX FEMUR SHAFT-CLOSED
I QM)UIt/P'OUCY HO.
I
I
,
SH01
o
."....~"
.:'... ~.;~;':,~..."
. .. ~..........\-"'t':.
, -' ;I...-'1'::u'~
.......~.-.. .~"'!
.
,---:"
I ClIlTJlU8SCIlla. NO,
I
d53.02 BRAIN HEM NEC-oKIEF CO~A
3URGCAL'ROCIDUAES
05/00/93
0510 <1193
79.05
78.15
CL, FX REOUC-FEMUR
APPLICATION OF c~TERNAL F
NO
;EllVICE DATE REF. NO.
ACCIDlHT DATE' TWI AnlNDIHQ PHYSlCW.
5/06/9~ 00:00 24dOO SCH~ENTKER, ED~ARO
DESCR1PTlON
~U~ AK Ur ~ c~
001 PEOS INTENSIVE CARE
001 I~TERMEOIATE CARE
001 PEOI~TRICt SEMIPRIVATE
250 PHARI1ACY
Z60 IV SOLUTIONS/500KLETS
270 MED/3UR~ SUPPLIES
300 LAbORATORY
.320 RADIOLOGY
351 RAOIOLOGY-CT HEAD
352 RADIOLOGY-CT aODY
360 OPERATING RM/O~ SUPPLIES
370 ANESTHESIA
391 BLOOD BANK/AOI1IN
410 RESPIRATORY THERAPY
4Z0 PHYSICAL THERAPY
450 EMERGENCY ROOH
'545 AIR AMBULANC E
.', 7J:arrw rim
Mldi99'J
Kb\AA1ti1:l..'~
~-~I
.'
Z DAYS AT
1 DAYS AT
2 OAYS AT
1,OUO.00
dbO.JO
4dO.OO
TOTAL CHARGES
AMOUNT
3,200.<l0
960.00
960 .00
135.72
54.00
1111.00
1,074.00
1,468.00
490.00
2,Z25.00
't,894.00
621.BO
2Z8.00
1,074.00
198.00
1,060.00
Z ,22.8 .00
376.00,
21,3L7.Sz.:
."
~
.
I ~~'FO.~:'" . '~:P;;~'~N'~' ~:S~R~cES'.
~~l"'" ~ISS~"'URlD
~ DANIEL A PUZZO,
~ 336 LOCUST POINT ROAD
~ MECHANICS8URG PA 17055
j ,..
I 'ljAE1.AnoHTC'ATlIHT IOCIALllCURlTYHUMllA
~ FATHER 999-99-9999
oJ
. . r.
..~~.., ...
.""~.~
" ..;-.t;..~ "'
. . .';:;~
'.. . ",'
t.':' ',. -....'.
.~. ..,~,. ...'.. '. . ..~.. ~.....,..r...~",
...... ...- ~.:.'''''''' ", .
ClAlW DAm PAGa NUIoIUII
06/01/93 1
'IRICO COVIMD IY 1KI CLAIM
0'$/06/93 05/11/93
IHSUAAHCa""","" _
OHIO CASUALTy INS~RANCE
CIIIOUP I'OUCY HClDlII
~~
...
'"
'"J
"
FEI NERkAN GROUP
P 0 80X 2679
HARR ISDURG
AUTO INS
PA 17105
CIIIOU'/POUCY """'""
CIRnFICA'T'IIIUIICRlIEl\ NUMHR
'DPD02ZS0651t
DHI 0S:/06/09311.. Is:o:o.5'J..D~~9-~
11
:. 'ATIENT HAMI
PUZ:LO~DEBRA.L""""""n.;,."1.':':'. .'
. O~ERIHSURANCEIHDCAnD'YHOSPrrALMCOADS
;' NAME o,r INSURED
'~'40NE
~ QW1NO$IS
'.821.01
I Nl,ATIC)ITO'ATDI' I WSUJ\NCICAJlUUe:,.
I I
I I
I I
I GIlOUl'II'OUCY 10).
I
,
I CIRT JIU\lSCAI8, NO.
.
FX FEMUR ,SHAFT-CLOSED
, .
. 853.02'. BRAIN HEM NEC":c3RIEF COMA
SURG~PROCEOURES
! ~ 05/08/93 79.05
'.; OS/06/93 76.1S
.. AtC:CEHT AfLATtD WORK RELATED
'.
. SERVICE DATE REF, NO.
=> U u
QS/06/9300101..04
J5/06/9300 10 1422
,JS/06/9300 104046
OS/06/930010411
J5/06/93 0104409
~5/06/9300104414
J51 06/9 300 10't't 1
J5/06/9 00104431
J5/06/9300104440
~5/06/9300104441
J5/06/93001044S5
';5106/9 00104642
'JS/06/9 00104650
')S/06/9 0010466
)S/06/9300 104665
JS/06/9 0010S0S2
'1S/06/9 0010S412
iJ5/06/93 010S61
;PS106/9 001014
fjS/06/9 0010 "
'!:JS/06/9 0110
f.lS/06/9 110463
":IS/06/93 110463
.
~5/06/93 1104645
~S/06/93 0307101
~
iJ5/06/93
;
~S106/93
~5/06/93
I
CL FX REDUC-FEMUR
APPLICATION OF EXTERNAL F
ACCIDENT DATE' TIME AnENDINQ PKYSlCLAN
S/06/9~ 00:00 24800 SCHWENTKER,
DESCRIP'I1ON
wAI\t:
AaO RH & ANTIbODY SCREEN
STAT CROSSMATCH 2 UNITS
1'10 FRAC TI;),~ OF C PK <.Y /'lASS
BLOOO GAS PANeL
2 AT
STAT AMYLASE, aLuOO
STAT ALKALINE PHOSPHATASE
STAT iHLlRU5IN TOTAL
STAT POTASSIUM (~), ~LOJD
STAT CPI<.
STAT MB FRACTION OF CPK
STAT SGOT (AST)
OP CREATININE, BLODO
OP ELECTROLYTE PROfILE 48
OP GLUCOSE, BLOOD
DP UREA NITROGEN (BUN), BLOOD
PARTIAL THROMBOPLASTIN TIHE
STAT COMPLETE BLOOD COUNT
OP CDHPLETE aLOOD COUNT
~~~~~M!&~~U~iHE
~dP ~dtA~IUH (K), BLOOD
.OP CI;tJ,.P1UDE,8LODD
1 ();B93lTAL, 8LOOD
-OP SODIUM (NA), 8LOOD
\.o..~ ~Ei/
r\KKI::ra.::... 2.. AT
fEW ANY
2. AT
C-SPINE ~-3 VIEWS
PELVIS. 1~2. VIEWS.
2. AT
EDkAR.O
YES
NO
AMOUNT
1,600.:1
87.00
141.00
34.00
1413.00
74.00
EACH
58.00
LEVEL
101.00
EACH
39.00
29.00
29.00
26.00
35.00
51.00
29.00
12.00
.00
11.00
12.00
21.00
32.00
17.00
15.00
15.00
12.00.
.12.00:
12.00.
12.00.
lL6.0Q.
I
61.00
EACH
2:::J
L~2..0'
..
EACH
,J.... .c...... Ii.
..
I CUJM'~k"'" , .~' ", '.' :
_ . " '. INPATIENT
=- MWI NfIJ AOOMII OP NUMD
-
-
~
;3
'5
r'
. ,
~ SERVU:'eS' ,
J
"
;1,,':':;' ". ...,...~.~.{~"'I.~~"'~'i
..... ..... ._.....:,. . ..A.O) ~ ..~_....:.'O...,.
-.. . . .._...,~ .... ',' --. ..~~....'
. . ' .
ClMIDATII ,AGa_
DANIEL A PUZZO,
336 LOCUST POINT
~ECHANICS8URG
ROAD
PA 170SS
Ob/01/93 2
NJVOO COVIfIIID IY nos a..AIM
05/06/93 05/11/93
INSUMNCI ClJMPNIY.w..1
OHIO CASUALTY INSJRAN:E
QIIOUt' I'OUCY HCUllII
IOCW. aacuRITY NUMlIR
999-99-9999
FEINERMAN GROUP
POBOX 2679
HARR ISaURG
AUTO INS
~
..
>>
~ PAlaHT NAMI
'PUZ'ZO~D EBRJ.;:l!"'.....~...,~. ,
: QTMIRINSURANCE tHDCATEDIYHOSPrTAL RECOAOS
NAME Of HSUREO
:, ONE
PA 1710S
ACCOUHT NUOlll&II
,. 0'$n03 L;..a 126,
ISIlI'OS'/-I!l'l93T
I MATDl TO 'ATEHI' I 1NSUf\AHCa CAIlAJ."
I 0 I
I I
I I
. .
, GROUPIPCUCY NO.
I
,
t ClIIT .lSU8SC1WI. NO.
t
t
I
.
: DIAGHOStS
.~21.01 FX FEMUR SHAFT-CLOSED
"J SURGCAL PROCEDURES
~ 05/08/93
I 05/06/93
853.02 8RAIN HEM NcC-6~IEF COMA
79.0S
7a.1S
CL FX RoEOUC-FEMUR
APPLICATION OF EXTERNAL F
; ACalOO'fiO.Aml WORKAELATED
.1 YES NO
SERVICE DATE REF, NO.
=>
ACCIDEHT DATE l nME AnENOtNQ PK'l"SICIAH
S/06/931 00:00 24600 SCHWENTKER, EUWARD
DESCRIPTlON
AMOUNT
1
2 AT
PORTABLE EXMl
3 oAT 00.00
C T AdDOMEU ENHANCED
CT C-SPINE UNENHANCED
CT PELVIS UNENHANCED
CT HEAD UNENrlANCEO
ACETAMING?HEN 120 MG
2 AT
ACETAMINOPHEN 600 MG
SUCRALFATE 100l1G
AIRWAY, NASOPHARYNGEAL
AM8U BA G-PEDS
PULSE OXIMETRY
SINbLE LINE SET UP
ARTERIAL INSERTION
MONITORING OA Y
STAR TER KIT
RESUSCITATION/TRAUMA
CASTING CHARGE - MAJOR
00421! P.:tiftL.A~rtlI'i\COLLAR 0
0046 (: 2' :t.AJ~~Gtl 9Al1!M SUMP 1l,14,16!18
0046 I!'LODD GAS' KIT
0046035 .J:iND.rR-J.,D.I;,
0046061 ~g 4.li10~
2. AT 8.00
S~DIGIT DISPOSABLE
'l1EP.f.CROOR1P
o , 1. oAr
TWIN SITE: EXT TU8ING
2; AT 2.DO EACH'
0046122 HEMOCULT ~ GASTROCULT PROCED
5&.00
EACH
198.0C
JS/06/93
JS/Ob/93
JS/06/93
;PS/06/93
J5/0b/93
J 5/ 06/'13
'J5/0b/93
~S/06/93
')S/06/93
JS/06/93
;)5/06/93
..) S/06/93
-)S/06/93
)S/06/93
-:.)S/06/93
tJS/06/93
1'5/06/93
. ~5/06/93
~S/Ob/93
~S/06/93
"'iJS/06/93
,
if
iJS/06/93
1'iJ5/06/~3
5106/93
o S/06/93
"'i\c/ "'1../") ~
EACH
0310S19
03105bO
0310566
0310501
02452d5
1,176.00
531.00
518.00
480.00
4.2C
2.10
EACH
024538S
0247965
0711019
0711088
0711093
0517202
OSl7303
0517402
OS17S04
0042005
0042201
2.10
7.80
16.00
59.00
42.00
7.3.00
36.00
64.00
43.00
149.00
.81.00
56.00
3.00
S .00:
9.00
16.0Q,
EACH
!
31.0Q
12.00
EACH
,6,.00
I
ft..oei
I
, ft..0 (T
'50.0
1"'\''''.L1'.", enl:v "'tC'COTT""= IC::TIIO
35.00
29.00
29.00
26.00
.00
29.00
32..00
39.00
26.00
26.00
2.6.00
2.6.00
S8.00
10L.OO.
132..00
I.~~i:: .O;:::TL; 0 ~~ 0
~AHDADOAUSOI' IHIURlO
~ DANIEL A PUZZO,
~ 336 LOCUST POINT ROAD
~ ~CHANICS8URG PA 170SS
~
~IW.ATlOHTO '''T1EN'f IOCLIL UCUlVTY NUIlIIIR
i FATHER 999-99-~999
......a,AI.no
.
oJ
. If--;:.;r.~j.: :..:~';. ~ - '.i'.~ .
.. ' .. '...-. :.1.r'".,.l';::..l\~ ':l<-' '
. .....:ll. of. ~.'_..:r..,.~ _,": 0'... ': -:"'"
;" '.'- :."
....... ~....-.
. .'.,,~.....,,"..
.... .~r:-:~""
.' .,.' "'.."-
CUlU DAta 'AGaHlA8lll
06/01/93 3
PIl\IOO CClYlIWII' 1lGl CUlU
OS/06/93 05/11/93
IHSUAANC:&""","" _
OHIO CASUALTY INSURANCE
GRCUl' I'OoJCT HClDlII
FEINERHAN GROUP
P 0 8DX 2679
HARRIS8URG
AUTO INS
PA 17105
GRDUI'1fIQJCY HUMIVI
I ClRmCATIIIUlSCl\Illll HUMllII
DPD02250654-
I$"IIa5'IDD'/.~
i
;'ATlIHTHMlI ACCOUHTNUMIII\
. PUttO~DEBRA\!C'~. .. ~l"'_>>~'" 05'7203"L:laT26'" 8/05'/'B
O'1l'tIA IHSUf\ANCE IHOtCAnD IY HOSPrrAL.RECORDS
NMlEOFaHSURED .IlILATlCNTO'AnEHI' ,IHSUMHCICAMlER
I I
I I
t !
'WNE
I GRQUPI?'DUCY NO.
I
I
,
I ClIIT JlUlSCI\l8, NO.
I
,
. llIAGNOSl'
~21~01 FX FEMUR SHAFT-CLOSED
853.02 8RAIN HEM NEC-3RIEF COMA
IUAG~PROCEDURES
I 05/03/;3 79.05 CL FX REDUC-FEHUR
05/08/93 7a.15 APPLICATION OF EXTE~NAL F
ACc:CE.'(l'R!lATtD WORK RELATED ACCIDENT DATI' TIME ATTlNDtNQ PHYSlCw.!
yES NO S/Oo/9~ 00:00 24800 SCHhENTKER, ED~ARD
DESCRIPTION
)S/07/93 0104406
JS107/9300104426
JS/07/9300104429
JS/07/93 0104431
J5/07/93 01044S0
JS/07/9 0104460
JS/07/93 0105412
')S/07/93 010S418
JS/07/9 05104431
J5/07/9 S104432
')S/07/93 S104437
, ')5/07/93 5104445
. 'JS/07/93 Ol~
PS/07/93 0
'::JS/07/93 0
.
I
JS/07/93 024S2-AI
!
~5/07/93
JS/D 7/93
JS/07/93
PS/08/9 003901,
PS/08/9~ OH003
65/06/93 OH0052
U be t: l.J
NASOLORAL TRACHEAL SErUp
LIFT-OFF PATIENT CHARGE FLIGHT
PATIENT CHARG~/AIR HILE
19 AT 57.00
PEDS INTENSIVE CARE
dLOaO G.\S PANEL
2 AT
STAT HAGNESIUM
STAT CALCIUM, BLOOO
STAT PHOSPHORUS
S TAT r.flGf/l$_~ ~ -tl<J., ..BLOOD
STAT:.l:.c.IHZTRJ.t:YH,,'pijDF1LE 104
ST A Tlj~~~i;:;:!J6'I.'OOO':"
STAT COMPLETE 8LOOD COUNT
STAT DIGf~eNf~~L~
*STAT POf'ASt'Ll1\ '[1(1, BLOOD
-STAT f~~D..R, p'LOpD
.STAT Cdil.TDUC,. .8~ODD
*STAT aill1tU1t:~(~~;',aLOOO
re~iM~IS:.~~~= 'ANY LEVEL
~dk~BLI: EXAK
2. AT 66.00
10ElBiiINOPHEN 120 HG
2 AT 2.10
mNOPHEN 600 KG
ATE 100MG
;.~ ofJE BlTUS EGGc.RATE.
. INTERMEDIATE CARE
O.R. TIME ~ LSHIN INCR-3.0
13 AT '175'.00
MAJOR SET-UP, ADD.SUPPLIES
AMOUnT
1 . 0
25.00
1,14S.00
1,063.00
EACH
712108
1,600.00
148.00
74.00
EACH
EACH
..
.4-.20
EACH
711503
FTE:
EACH
2..10.
T.8D:
14-.00:
. _ 860 .OW
Z~2.75,.llj
834-.0'0
20.0r
-. ----....... ,---..
,. .
.. .... ..,
fl. . I.... .. . ..
~M~' , .. SEF\VICES .
. .
oJ
"
4E .
INPATIENT
.::- NAMa >>GADORISI OP WSUND
~ DANIEL A PUZZO,
~ 336 LOCUST POINT ROAD
~ ~ECHANICS8URG PA 17055
';
:. MlATlOHTOPAnlHT IOCW.UCUM'YNWIIP\
~ FATHER 999-99-9999
ClAlloIDAn
06/01/93
'11IlOCl CllVIIWlIY THII ClAlW
05/06/93
05/11/93
""IUfWCI COWNfY MAMI
OHIO CASUALTY INSURANCE
GROUP 'OUCY HOLDE"
. MAA. Q,M& TO
.
3.
FEINERHAN GROUP
P 0 80X 2679
HARRISSURG
GAOuPI1'OUC'l' HUUII"
AUTO INS
4
ACCOUI<T ........A
0572031-3126
DH 0'$/06/93" IS'05'/!~/9~'
PA 1710S
~
~'ATI!HT~
puna DE8RA L
. OllftRIHSUA.AHCE INDICATED IY HOPrTALNCOADI
NAA4 OIIIGURlD
i NlAT'ICINfO'AOOfT ! INSUfWrCl~I"
I I
I I
I GAOUPI?CIUCY NO.
I
I
I
,
lONE
llltAQNOSIlI
321.01 FX FEMUR SHAFT-CLOSED
. SURalCAL I'AOCEDuRES
4 OS/06/93 79.05
! OS/06/93 78.15
i AC;COO NlATCI WORK RILATEO
I YE S NO
SfRVICE DATE REF. NO.
=> b
J5/08/95 0410080
OS/08/93 04~0106
OS/08/93 04b4000
OS/08/93 046~000
i
,
OSlO 8/93
l
OSlO 8/93
I
I
05/08/93
~S/08/93 04b400D
1
~S/08/93
~S/08193
)S/08/93
JS/08/93
)S/08/93
\lS/08/93
'JS/O 8/93
PS/08/93
~5/06/9 3
i)S/08/93
JS/08/93
I
')S/08/93
,
)S/06/93
',l5/08/93
J5/08/93
I
b5/08/93
;,)S/O 6/93
8S3.02
BRA IN HEM Nc c-aR IeF CO'! A
CL FX REDUC-FEHUR
APPLICATION OF eXTERI~AL F
ACCtDENT OAtil TIME AntNDING PWYIIC~
S/06/93:00:00 24800 SCHwENTKER,
DESCRIPTION
EL).1 A RIl
,; U UI~
OR THO Dit ILLS
SKI~ STAPLES - ~LL
ORTHOPEDIC O~ SUPPLIES
ORTHOPEDIC OR SUPPLIES
4 H, 216.00
ORTHOPEDIC OR SUPPLIES
It AT b.OO
ORTHOPEDIC JK SUPPLIES
2 AT 64.00
ORTHOPEDIC OR SUPPLIES
2 AT 78.00
ORTHOPEDIC ~K S~PPLIES
2 AT 64.00 EACH
2-1/2 TO 3 HOURS-RECOVERY ROOM
ANESTHESIA TIME-HOSPITAL COMPONENT
FLUDRO MORE THAN ONE HOUR
CEFAZOLIN lO GH/SO HL
SUCRALFATE 100MG
I V DEXTROSE 5%-.45 SOO C 500
AEROSOL/GAS THERAPY START
NEBULIlER/MHH DAY
.
VENTILATOR START
VENTILATOR EQUIPMENT DAY
EXTENDED SERVICE
2 A r 37 . 00
TRANSPORT INTERNAL INIT
INFANT CANNULA/DISPOSABLE EQUI.
EAR OXIMETRY PROBE
MONITORING START
2. AT
END TIDAL 1:02.
OXIMETERY DAY
EACH
EACH
EACH
EACH
0422008
OS02000
0307551
0245..72
0247965
0621033
0514102
OS141D't
0514202
OS14203
OS14504
EACH
0514S12.
0514802
051460S
0514902.
37.00
EACH
. .
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e ".U
f CIIn' ISUUCM. NO.
I
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AMDUNT
O.
125.00
47.00
165.00
872.00
24.00
128.00
lS<<:..OO
16:hOO
376.00
62.1.80
173.00
3.80
7.ao
6.00
15.00
52.00
37.00
326.00
74.00
28.00
4.00
2.5.00
74.00
L03.00
90.00
I .. ...'...'...... .
CLAIM' FOR' - " . .: \ SERVICES
. .' ;NPA TIENT
,=NAMI N4fJ ADOMSI OIlN1UR1D
~ DANIEL A PUZLD,
~ 336 LOCUST POINT ROAD
~ -HECHANICSaURG PA 17055
~t
:.;N1.ATIOH TO 'ATlIHl'
;; FA THER
FE I NERI'IAN GROUP
P 0 80X 2679
HARRIS8URG
.,;
.. 'AntHT HAUl:
, PUZ.~DEaRA. L
. ' "
-'
,
:.~~.7
Cl.AIM DATI
,AlIa ......,.
IOC&AL IlCURlT'l' NU".lR
999-99-9999
06/01/93
HAIOD COYIIUD IY THlI c:u"N
05/06/93
IHSUMHCI COMPANY NAMa
05/11/93
5
OHIO CASUALTY INSURANCE
OIlOUt' I'OUC'I_
AUTO INS
PA 17105
I CU.1V1CATIfSU8SCRlI.A HUMBER
DPD02ZS0654
~05/.06/.9~.. I.Sc 05A1./,930
GAOUPJPQJCY NUU8l.A
_01,;:. ':;?r
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- ~.",
_~ONe
= OT)otI!A IHSUAANCE IOCAnc IV HQUrrALNccw.OI
NAME Ofl' INSURED
I NlAT1tWTO.A1'INT ,tNSUAAHCICNUUlR
I I
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I .
I OIlOUf'II'OUCY NO.
I
I
I CUT JlUlSCRII. NO.
I
I
I
.
. DCAQNOSlS
.821.01 FX FEMUR SHAFT-CLOSED
t:
FeMUR
ACETAMINOPriEN 120 MG
CEFAZOLIN 10,GM/SO ML
CEFAlDLIN 10 GH/SO foiL
TRIHETHO&ENZAHIO~ 100 M~
2 AT 2.10
ACETAMINOPHEN 000 MG
TRIMETHOdENlAHIDE 100 MG
. 2 AT 2.10
hCETAMINOPHEN 320HG/10.15ML
2 AT 2.10
ACETAMINGPHEN/CODEINE SML
I V DEXTROSE S%-.45 SOD C 500
2 AT 6.00 EACH
~IT ADMISSION ADULT
OXIMETERY DAY
PEOIATRIC, SEMIPRIVATE
CEFAZDLIN 10 GM/5D ML
1l~~~U1Cffi'j:NZAMIDE 100 MG
lQY\IJ~GEr.J1!.I>EROXIDE 16 01.
8ACITR.-POLYMYX-NEOM 15 GH
N iOV.~TRDSE 5~-.45 SOD C. 500
~~~ a AT 6.00 'EACH
Ob21034, I V DEXTROSE 5X-.45 SOD C 1000
RRISBURG 2 AT b.OO EACH
o Lf4n~PSION ADULT
'~~t'!~~SIDN IVAC UNVENTEO BUR
PT EVALUATION 16-30 MIN
PT TREATMENT 16-30 HIN
ETOHlDA TE: 2. HG/ML
FENTANYL CITRATE S'HL
SUCCINYL CHOLINE 200 MG/I0 ML
!TQ'JPT"l'E ~IJLFbT'E t MG
.; SURGICAL PROClD\JRES
05/03/93
05/00/93
~IlllATUl WORKRELATlD
yE S NO
, SERVICE DATE
REF. NO.
'OS/09n3
J5/09/9
J5/09/93
J5/09/93
J5/09/93
0307306
024S2tl5
024S472
0245472
024S659
eS/09/93 024S98S
JS/09/930J246539
05/09/93002S1174
~5/09/9 00021033
JS/09/93 0665300
JS/09/93 0514904
JS/10/9 00039001
-JS/I0/93
,JS/10/93
~S/10/9
jlS/l0/93
'tl5/l0/9
~
)5/l0/93
~
,05/l0/93
:,)S/10/93
,)S/10/93
'J5/10/93
.
'05/11/93
~5/11/9
ES/11/93
.1~/l1/0"
0245472
~~;
02'itb31
062.10
6S3.02 BRAIN HEM NEC-aRIEF COMA
79.05
78.15
CL FX REOUC-FEMUR
APPLICATION OF EXTERNAL F
ACetOlHI' DATE & TaME AnENDINQ PHYSICIAN
5/06/9~ 00:00 24600 SCH~ENTKER,
DESCRIPTION
c
AMOUNT
4
136.00
2.10
4.61
5.41
...20
.. 2.10
4.20
4.20
2.10
12 .00
5.00
30.00
480.00
5.41
2.10
2..10
2.l8
12.00
12..00
~.oo;
20.00.
66.00
66.00'
H.6~
2. .lC~
2.10'
3.l:
EDWARD
EACH
EACH
EACH
724701
I . .,' . ... ..
::;: ~... ", .....: ....
iiI ~M FOil h
~. INPATIENT
.
. ,
SERVICES
.' I.
a frW4 AND ADOMU M ..aURlD
..
E1
'"1
CLAIM CATI
'AOa ......11I
~
=-i IW.AnoNTOI'AT1INT
:::: FA THER
,DANIEL A PUZZO,
~36 LOCUST POINT
I1ECHANICS8URG
ROAD
PA 170SS
06/01/93
PUIOO CQVlIW) IY na CUJM
05/06/93
6
OS/11/93
IQCW.IICURt1"Y HUM.1ft
99~-99-9H9
tNlURAHCI CC)MPAHY NAMI
OHIO CASUALTY INSJRAN:E
GAOII' I'OUCV HClDlII
'1
FEINERHAN GROUP
POBOX 2679
HARR ISaURG
AUTO INS
=
PA 17105
QROUP/POUCY HUMIIER
CIR1'1P'ICATI,'~UlSClUllft NUM8IJIl
- PATIIHT NAME ACCOUNT HUMIIA
PUCZO. DE8RA L OS72031-3126
OTHER INSURANCE INDICATED IY HOSPITAL. RECORDS
HAME OJ' INSUAlD I RlLAnoN TO PAfWft I INSURANCE CAMIER
I I
I I
, ,
OM 05/06/93
IS 05/11/93.
t QROUP/POUCY NO.
I
I
I
I CI"TAU'SCRI.. NO.
I
I
I
FX FE~UR SHAFT-CLOSED
653.02 BRAIN HEM NEC-dRIEF COMA
$URa~'ROCEDURES
os/oa/93 79.05
OS/08/'i3 79.1S
llC::tlHT RaATiO WOAJ( REL.ATtO
YES NO
; SERVlCE 01. TE
,j
05/11/93
OS/11/93
rS/11/93
I
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I
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!
REF, ND,
va
Ob21034
0670350
OS70032
CL FX !lEDUC-FEMUR
APPLICATIO~ OF EXTcR~AL F
ACCIDENT DATE & TiME AnENDING PHYSICiAN
5/06/93100:00 24aO~ SCH~cNTKE~.
DESCRIPTION
.;,- .4;) ,;"UU I... :>u
I V 5~-.4S SOD C 1000
SET IkFUSION IVA~ UNVENTEO ciUR
PT TREATMENT 010-30 o'\I:-l
EO"ARD
AMOUNT
6. 0
6..00
20.00
66.00
TOTAL CriArt..eS
21.317. S 2
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Exhibit B
-
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.
. .
SETTLEMENT AGREEMENT AND RELEASE
This Settlement Agreement and Release ("Settlement Agreement")
is entered into by and among the fOllowing parties I Deborah Puzzo, a
minor, by and through and The Ohio
Casualty Insurance Company (hereinafter collectively referred to as
"the parties"). "Claimant" shall collectively mean Deborah Puzzo, a
minor, by and through and the heirs,
executors, administrators, personal representatives, successors and
assigns of same, and "Insurance Company" shall collectively mean The
Ohio Casualty Insurance Company and the successors and assigns of
same.
I. RECITALS
A. On or about May 6, 1993, Claimant sustained personal and
physical injuries as a result of the alleged tortious conduct of an
underinsured tortfeasor, all of which is hereinafter referred to as
the "Occurrence". In connection with the Occurrence, Claimant has
asserted a claim against Insurance Company in accordance with the
underinsured motorist coverage provision of Claimant's policy with
Insurance Company.
B. The parties desire to enter into this Settlement Agreement
to provide, among other things, for certain payment(sl in full
settlement and discharge of all claims and actions of Claimant
against Insurance Company for damages arising out of or due to the
Occurrence, on the terms and conditions set forth herein.
NOW THEREFORE, it is hereby agreed as follows I
II. RELEASE
In consideration of the lump sum payment set forth herein and
the promise to make the periodic payment(s) set forth herein,
Claimant hereby releases and forever discharges Insurance Company
from any and all past, present or future underinsured claims for
damages for personal and physical injuries which Claimant has or
claims to have against Insurance Company, for or in any manner
arising out of the Occurrence. This release and discharge shall be
a fully binding and complete settlement among all parties to this
Settlement Agreement. This release is entered into in settlement of
an underinsured motorist claim arising out of the Occurrence.
,.:,.;.rr".
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,
. .
III. UNKNOWN INJURIES
Claimant fully understands that Claimant may have suffered
personal and physical injuries that are unknown to Claimant at
present and that unknown complications of present known injuries may
arise, develop or be discovered in the future, inclUding, but not
limited to, subsequent death or disability. Claimant acknowledges
that the consideration received under this Settlement Agreement is
intended to and does release and discharge Insured and Insurance
Company from any claims for, or consequences arising from, such
injuries and the Occurrence I and Claimant hereby waives any rights
to assert in the future any claims not now known or suspected even
though, if such clai~s were known, such knowledge would materially
affect the terms of this Settlement Agreement.
IV. PAYMENT(S) TO CLAIMANT
A. Lump Sum. Claimant has received Five Thousand Dollars and
No Cents ($5,000.00), receipt of which is hereby acknowledged.
B. Periodic Payments. Insurance Company hereby agrees to make
the following annual payments to Deborah Puzzo. The sum of Five
Thousand One Hundred Forty-Six Dollars and Thirty-Four Cents
($5,146.34) per year, shall be payable to Deborah Puzzo commencing
August 5, 2004, and shall continue through August 5, 2007 (four (4)
annual payments). If Deborah Puzzo dies before August 5,2007, the
payments set forth in this Paragraph IV.B shall be made as due to
, upon proof of death being furnished to
Insurance Company, or to such other beneficiary or beneficiaries as
Deborah Puzzo shall designate, in writing, after reaching the age of
majority and prior to her death, to Insurance Company. No such
beneficiary designation or revocation thereof shall be effective
unless it is in writing and delivered to Insurance Company.
C. Nature of Payment(s). All sums paid to Claimant pursuant to
this Settlement Agreement constitute damages on account of personal
injuries or sickness, in a case involving physical injury or
physical sickness arising from the Occurrence are intended to fall
within the meaning of Sections 104(a) (2) of the Internal Revenue
Code of 1986, as amended.
V. FINANCING OF PERIODIC PAYMENT OBLIGATION
A. Insurance Company as Obligor. Insurance Company shall, at
all times, remain directly responsible for the continuing obligation
of making all periodic payment(s) set forth in Paragraph IV.B.
Insurance Company's duty to make such periodic payment(s) shall at
all times be, and is, an unfunded and unsecured obligation to pay
money to Claimant in the future and Claimant can rely solely on the
general credit of Insurance Company for collection of the payment(s)
2
~ "
set forth in Paragraph IV.B. Insured has no duty to make such peri-
odic payment(s).
B. Third Party Payment. It is understood and agreed by the
parties that, as a means of providing a source of funds for Insur-
ance Company to satisfy its obligation to make periodic payment(s)
to Claimant pursuant to this Settlement Agreement, Insurance Company
will purchase, for its own investment purposes, an Annuity Contract
from The Ohio Life Insurance Company (the "Annuity Contract")
immediately upon execution of this Settlement Agreement. Insurance
Company shall be the owner of the Annuity Contract and shall have
and retain all rights of ownership in the Annuity Contract. For its
own convenience, Insurance Company shall direct The Ohio Life
Insurance Company to make the periodic payment(s) directly to the
respective payees designated in Paragraph IV.B. Such payment(s)
will be applied against the obligation of Insurance Company to such
payees, as set forth in this Settlement Agreement.
C. Status of Claimant. Claimant acknowledges that Claimant has
no right to receive the present value of the payment(s) due Claimant
pursuant to Paragraph IV.B, or to control the investment of, or
accelerate, defer, increase or decrease the amount of any payment(s)
required to be made to Claimant. Claimant shall only be entitled to
receive the payment(s) specified in Paragraph IV.B when due.
VI. NONASSIGNMENT BY CLAIMANT
The periodic payment(s) to be received by Claimant pursuant to
this Settlement Agreement are not subject in any manner to
anticipation, alienation, sale, transfer, assignment, pledge or
encumbrance by Claimant.
VII. ADEQUATE CONSIDERATION - DENIAL OF LIABILITY
Claimant agrees and acknowledges that Claimant accepts
payment(s) of the sums that Claimant is to receive pursuant to this
Settlement Agreement as a full, complete, final and binding
compromise of matters involving disputed issues regardless of
whether too much or too little may have been paid; that payment(s)
of the sums to Claimant shall not be considered admissions by any
party hereto of any liability or wrongdoing; and that no past or
present wrongdoing on the part of any party shall be implied by any
payment(sl.
VIII. ENTIRE AGREEMENT
This
Claimant
herein.
Settlement Agreement contains the
and Insurance Company with regard
There are no other understandings
entire agreement between
to the matters set forth
or agreements, verbal or
3
"
I
I,
I
I
ii
I'
I
I
,
.
t "
otherwise, in relation thereto, between the parties except as herein
expressly set forth.
IX. READING OF AGREEMENT
In entering into this Settlement Agreement, Claimant represents
that Claimant has completely read all terms hereof and that such
terms are fully understood and voluntarily accepted by Claimant and
that Claimant has been adequately represented, or has had
opportunity to seek representation, by counsel of Claimant's choice.
X. TRUST OBLIGATION
Claimant agrees to take, through any representative designated
by Insurance Company, such action as may be necessary or appropriate
to recover damages suffered by the Claimant in the Occurrence from
any person or organization who may be legally liable therefore.
Claimant agrees to hold any monies recovered by Claimant from such
person or organization in trust and paid first to Insurance Company
to the extent of the payment(s) set forth in Exhibit A plus the
amount incurred by Insurance Company for expenses, costs and
attorney fees in connection with the recovery of such monies,
provided, however, any monies remaining after such payment to
Insurance Company shall be retained by the Claimant.
XI. SUBROGATION
Claimant hereby assigns and transfers to Insurance Company each
and all claims and demands that Claimant has against any other per-
son, firm, property or corporation, arising from or connected ~ith
the Occurrence, and Insurance Company is hereby subrogated in
Claimant's place and to Claimant's claims and demands and Insurance
Company is hereby authorized and empowered to sue in Claimant's name
or otherwise.
XII. FUTURE COOPERATION
Claimant covenants that Claimant has not released or discharged
any claims or demands arising out of the Occurrence and that
Claimant will assist and cooperate with the representative
designated by Insurance Company to recover damages suffered by
Claimant. Claimant further agrees to execute any and all
supplementary documents and to take all additional actions that may
be necessary or appropriate to give full force and effect to the
terms and intent of this Settlement Agreement which are not
inconsistent with its terms and which may be necessary to recover
such damages.
4
~.
I
.
. ,
XIII.
INDEMNIFICATION
In further consideration of the payment(sl and the promise to
make future periodic payment(sl set forth herein, Claimant agrees to
indemnify and hold harmless Insurance Company and all parties ~
released against any and all medical or other liens, or claims that
are, have been in the past, or may be in the future asserted against
anyone as result of the aforesaid Occurrence.
XIV. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT
This Settlement Agreement has been negotiated by the parties.
Claimant warrants, represents and agrees that Claimant is not
relying on the advice of Insurance Company, its counsel, or anyone
associated with Insurance Company as to the legal and income tax or
other consequences of any kind arising out of this Settlement
Agreement. Accordingly, Claimant hereby releases and holds harmless
Insurance Company and any and all of its counselor consultants from
any claim, cause of action or other rights of any kind which
Claimant may assert because the legal, income tax or other
consequences of this Settlement Agreement are other than those
anticipated by Claimant.
XV. COURT APPROVAL
Claimant represents that Claimant has received any and all
necessary court approvals to enter into this Settlement Agreement.
XVI. CONTROLLING LAW
This Settlement Agreement shall be construed and interpreted in
accordance with the laws of the State of Pennsylvania.
Dated:
Deborah Puzzo, a minor, by and through
Dated:
The Ohio Casualty Insurance Company
By:
Title:
5
!:vhlhlt ,...
.
,
.
RELEASE OP CLAIMS
For and in consideration of the payment to us of the sum
of Fifteen Thousand Dollars ($15,000.00), we, Daniel Puzzo and
Genelda Puzzo, individually and as parents and natural guardians of
Debra Puzzo, a minor ("Releasers"), do hereby release and forever
discharge Ohio Casualty Insurance Company, its parent and
SUbsidiary companies, agents, officers, employees and
representatives, of and from any and all actions, causes of action,
claims, demands, damages, costs, loss of services, expenses,
compensation, consequential damage, uninsured motorist claims,
under insured motorist claims 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 6th day
of May, 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
.
t,.... . ',. ~
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
corporations 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 Ohio Casualty 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.
It is further agreed that I will indemnify and hold
harmless Ohio Casualty Insurance Company, its parent and SUbsidiary
company, officers, agents, employees, insurers, assigns, and
representatives from anyand all liability arising from liens and/or
subrogation claims including any compensation or medical payments
due or claimed to be due under the law, state or federal regulation
seals this
day of
, 1994.
J
...~ ....
or contract.
We expressly acknowledge that all obligations to
satisfy such liens are that of releasor not releasee.
We certify that we are over eighteen (18) years of age,
that we are the parents and natural guardians of Debra Puzzo, 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.
IN WITNESS WHEREOF, we have hereunto set our hands and
WITNESSETH:
(SEAL)
Daniel Puzzo, parent and natural
guardian of Debra Puzzo
(SEAL)
Genelda Puzzo, parent and natural
guardian of Debra Puzzo
Sworn to and subscribed
before me this
day of
1994.
,
Notary Public
My commission expires:
., .
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DEBRA PUZZO, a minor, ~y
DANIEL A. PUZZO and JBNBLDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JBNBLDA
PUZZO, in their own riqht,
Plaintiffs
IN THE COURT OF COMMON PLBAS
CUMBERLAND COUNTY, PBHHSYLVANIA
CIVIL ACTION - LAW
NO.1 q~-I~'8'L
(' iM.L(? 'R WI-
v.
MICHELLE ASKINS,
Defendants
PETITION FOR COURT APPROVAL OF
MINOR'S SETTLEMENT
Pursuant to Pa. R.C.P. 2039, Daniel A. Puzzo and Jenelda
Puzzo, as parents and natural guardians of Debra Puzzo and in their
own right, by and through their counsel Zeigler and Zimmerman, file
this Petition for Court Approval of Minor's Settlement and in
support aver the following:
1. Daniel A. Puzzo and Jenelda Puzzo are the parents and
natural guardians of Debra Puzzo, a minor child, who was born on
August 5, 1986 and who is presently seven (7) years old.
2. Petitioners reside at 336 Locust Point Road, Mechanicsburg
Post Office, Cumberland County, Pennsylvania 17055.
3. Defendant is Michelle Askins, an adult individual, who
currently resides at 7073 Carlisle Pike, Box 164, Carlisle,
Cumberland County, Pennsylvania 17013.
.- ..
4. On May 6, 1993, Debra Puzzo was injured when, as a
pedestrian, she attempted to cross Locust point Road and was struck
by the Defendant's vehicle.
S. Debra Puzzo sustained a left femur fracture, a closed head
injury with brain contusion, a tongue laceration and cracked teeth.
Upon her discharge on May 11, 1993, her neurological symptoms had
resolved. Additionally, her left femur has healed and is in
adequate alignment, and she has full range of motion of all joints
with no tenderness, normal function, normal musculature, and equal
limb lengths. Debra Puzzo is attending school as a second grade
student and is able to engage in all normal activities. She is not
treating with physicians at this time. (See reports of Edward P.
Schwentker, M.D., attached hereto as Exhibits "A" and "B").
6. Petitioners have incurred the following medical expenses
for treatment of Debra puzzo, Ten Thousand ($10,000.00) Dollars of
which have been paid by Ohio Casualty [Personal Injury Protection
(PIP)], the Puzzos' first party vehicle insurance carrier, so that
approximately Nineteen Thousand ($19,000.00) Dollars remain unpaid
(less $14,900.02 as more specifically set forth in paragraph 7
herein):
'-~"'--.'~- .
,--~..._....-,-'
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321. 99
42.00
86.00
7.77
3.02
Jmn
5/6-5/11/93
6/1/93
6/15/93
5/6/93
5/6/93
5/6/93
5/6/93
5/6/93
5/6-5/7/93
5/8/93
5/8/93
5/8/93
5/11/93
5/18/93
5/18/93
5/11/93
5/20/93
5/20/93
9/16/93
PACILITY
AMOUNT
University Hospital MSHMC
University Hospital MSHMC
University Hospital MSHMC
University Hospital MSHMC
Silver Springs Ambulance &
Rescue Association
Pediatric Critical and Intensive
Care
Division of Emergency Medicine
Division of Neuro Surgery
Division of Pediatric Surgery
Division of Orthopedics
Division of Pediatric Surgery
Division of Anesthesia
West Shore Advanced Life Support
Services
Division of Radiology
University Hospital
Wal-Mart
Wal-Mart (Prescriptions & Antiseptic)
Kreamer Medical (Wheelchair and
Walker)
Kearns and Ashby, DDS
$ 21,317.52
354.00
86.00
2,345.00
125.00
350.00
50.00
275.00
495.00
2,080.00
55.00
1,026.00
356.10
137.00
TOTAL
$ 29,512.40
7. The Petitioners aver that the Commonwealth of
Pennsylvania, Department of Public Welfare, has submitted a
Statement of Claim, which is attached hereto and marked as Exhibit
"c" setting forth the providers, dates of service, and amounts paid
on behalf of Debra Puzzo. As noted in Exhibit "C", the total
amount of monies paid is $14,900.20 for which formal claim has been
made. Your Petitioner agrees that the Commonwealth of
3
.'
Pennsylvania, Department of Public Welfare, will be reimbursed from
the proceeds of the settlement in the amount of Twenty-five
Thousand ($25,000.00) Dollars, subject to any appropriate deduction
offered by the Department of Public Welfare that would benefit the
minor.
8. Petitioners have negotiated a settlement with Defendant's
insurance carrier to pay the policy limit of Twenty-Five Thousand
($25,000.00) Dollars. From that sum, medical expenses are to be
paid, with the remainder to be retained as set forth hereafter in
this petition.
9. The Petitioners aver that the settlement is in the best
interest of Debra Puzzo and that the settlement represents a full
and fair settlement of the case, equal to or greater than that
which may be obtained should the matter be fully litigated, in this
case, where Defendant would contest liability on theories including
the defense that Debra Puzzo was a "darting child" at the time of
the accident and the defense that, as reflected in the police
report, Defendant was traveling well within the speed limit at the
time of the accident (in this accident, which was investigated by
Silver Spring Township police, no violations were ascribed to
driver Askins).
10. Petitioners request the proposed settlement because they
consider it fair and reasonable, and in light of the facts of this
case, it appropriately compensates for the injuries sustained and
4
expenses incurred.
11. The Petitioners propose to place their daughter's
settlement proceeds in a federally insured account at a bank or
savings and loan association organized and existing under the laws
of the Commonwealth of Pennsylvania.
12. The Petitioners desire to be named as custodians of their
daughter's account.
13. The Petitioners desire to have the right to invade their
daughter's account prior to her attaining the age of 18, if it is
necessary to do so for the benefit of their daughter, subject to
prior court approval.
14. The Petitioners desire that the funds be made available
to their daughter, Debra Puzzo, when she attains her 18th birthday
on August 5, 2004.
15. The Petitioners will withdraw the action filed against
the Defendant and execute a general release, if this settlement is
accepted by the court.
16. The Petitioners' counsel, Paul L. zeigler, Esquire, Camp
Hill, Cumberland County, Pennsylvania, will receive none of the
proceeds of the settlement, as he is being paid from another
source.
5
- - ~,,- ^":
,,','t
WBBRBFORB, Petitioners respectfully request that this
Honorable Court approve the minor's settlement and appoint Daniel
A.Puzzo and Jenelda Puzzo as trustees and custodians of their minor
child's assets, after payment of outstanding medical expenses.
Resp
submitted,
By:
Paul egler, Esqu re
Suprem Court I.D. #09603
ZBIGLBR , ZIMMBRMAN, P.C.
355 N. 21st st., suite 304
Camp Hill, PA 17011-3707
(717) 731-1484
6
VBRII'ICATION
The undersigned hereby certifies that the facts set forth in
the foregoing Petition for Court Approval of Minor's Settlement are
true and correct to the best of his knowledge, information and
belief, and further states that false statements herein are made
subject to the penalties of 18 Pa. C.S.A. 54940 relating to unsworn
falsification to authorities.
~. "/)/,,/ ~J_ ". ....h-1 hl't _
_ _ _ _fL~ :1/ ( J-:t......)1
Jenelp Puzzo t/ U
,
Date: February~, 1994
6
.
Exhibit A
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PedIatrIc OrthopaedIc ClinIc Note. August 31, 1993
PAnENT: PUZZO, DEBRA
MSHMCI672031
PROBLEM: Fracture, laft famur,
ASSESSMENT: Debra la 7 yeara of age, She auatalnad a left femoral fracture and minor cloaed head
Injury In a motor vahlcla/padestrlan accIdent In May of 1993, She wa. trelted with an extern.' flxator
and healed her femur without difficulty, She retum. for re..valuatlon,
She haa a full range of motIon of all /olnta wIth no tendemll., She ha. normal function, She haa
normal muaculature and equai 11mb lengtha,
PLAN: She I. to return for clinIcal re-avaluatlon In one year'. time or earlier If any further problema
devalop,
Edwarda p, S
EPS/lm
cc: Weat Shore Family Practice
890 Poplar Church Road
Suite 108
Cemp HII/, PA 17011
Robert CII/ey, M,D,
Pediatric Surgery
M, S, Hershey Medica' Center
HerShey. PA 17033
Exhibit B
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(u' . '6"'" I ~.:/-'~
PEN N STATE
"
College of Medicine . University Hospital
The Milton S. Hershey Medical Center
.:dward.I', Schwclllkcr. M.I>,
Medical Dircclllr
Ullivc"ilY IllIspil.' RdlllbililllliulI Centcr
P,O. 80. 850
IImhoy, Pconsylvania 17033
(717) 531-7312
September 7, 1993
Dana M. Harris
Claims Representative
progressive Casualty Insurance Companies
P,Q. Box 4037
Harrisburg, PA 17111
RE:
Debra Puzzo
MSHMCII 572031
Claim Number:
Your Insured:
Date of Loss:
930178195
Michelle Askins
May 6, 1993
Dear Ms, Harris:
I am writing to you in response to your letter to me of August 6,
1993 requesting a medical report on Debra Puzzo.
.Debra Puzzo was treated at the University Hospital of the Milton S.
Hershey Medical Center for injuries sustained in a motor
vehicle/pedestrian accident on May 6, 1993. She was transported by
helicopter to the emergency room following her accident. She was
determined to have a closed head injury and a fracture of her left
femur. She was evaluated by our pediatric trauma surgeons and
received assessment by our pediatric neurosurgeon. She was
initially placed in traction for her femoral fracture and after she
was found to have stabilized with respect to her closed head injury
and found to have no other serious injuries, she was taken to the
operating room on the 8th of May, 1993 where her left femoral
fracture was reduced by closed manipulation and stabilized with the
application of an external fixator. This device stabilizes the
bone through the use of transcutaneous pins attached to an external
frame.
FOllowing the operative procedure, the patient's head injury status
resolved, She was begun on ambulation and physical therapy with
the use of a walker and was discharged to home on the 11th of May,
1993.
An Equal Opponunily Univmily
PROGRESSIVE
SEP 101993
COMt'AI'lII:;~
Page 2
september 7, 1993
(RE: Debra Puzzo)
She was subsequently followed through the pediatric orthopaedic
outpatient clinic.
On June 1. 1993 x-rays showed good alignment of her fracture with
callus formation, The external fixator was removed and she was
placed in a cast incorporating her left lower extremity and her
pelvis. On the 15th of June, 1993, the cast was removed and she
was begun on mobilization exercises. She was last evaluated by me
on the 29th of June, 1993. At that time she had a full range of
symmetrical motion of both hips. Her pinned tract sites had healed
completely. She was ambulating without the use of any external
support. She had knee flexion to 90 degrees without pain. She and
her family were advised to continue the range of motion exercises
to the left knee and were scheduled to be re-evaluated in 2 months
time,
The injuries that this child received in the automobile accident
included a closed head injury with brain contusion. She appears to
have been left with no sequelae from her head injury. She had
minor tongue lacerations and cracked teeth. It appeared to require
no intervention at the time of her injury, A dental assessment
would be required to determine whether there remained any long term
consequences of her tooth injuries. Final and most significant of
her injuries was a fracture of her left femur. This has healed and
appears to be in adequate alignment, She continues to limp and is
likely to do so for several more months. I would expect her limp
to resolve completely. She has the potential for developing a limb
length discrepancy secondary to overgrowth of the left femur. She
will be monitored for this complication, Should that complication
develop, some adjustment of limb lengths toward the end of growth
may be necessary through a relatively minor operative procedure
called an epiphysiodesis. The only other sequelae likely to remain
following the fracture of her left femur would be the scars from
the stabilizing pin sites, I expect the bone to heal completely
and to remodel back to its original state of strength and
alignment.
PROGRESSIVE
SEP 1 f) 1993
CUMl"ANIE::i
page 3
September 7, 1993
(RE: Debra Puzzo)
If there is additional information you require, please feel free to
contact my office. All records kept by me are kept in the main
patient chart of the Hershey Medical Center. These can be accessed
by contacting the Health Information Systems Department. All
billing is handled centrally and a detailed account of medical
charges generated from this child's hospitalization can be accessed
through the Accounts payable Department of the university Hospital.
Physician charges can be accessed by contacting University
Physicians Professional Billing Department.
Sincerely,
---il' "Jc-d!'(""t"..lec<.. );Y?k/.6-
Edwards P. Schwentker, M.O,-
Medical Director of Rehabilitation
PROGRESSIVE
SEP 1 I) 1993
COMt"ANJES
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Exhibit C
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, "~,~""",,t,i,. . .,T(o~(i;i"':ll~t'"", ....i..n.\.~.,.r.... . . .1Itl'i ~t,j. nfff~""
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J . ',"1' ,~,-,\~~"rll.,),'~"" \, n, . .L.~ I I."
". ":';':':':"(~'t',':: Department of Public Welfare.;....
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"'.'';;r.i
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01/06/1994
STATEMENT OF CLAIM
RECIp NAME : Puzzo, Oebra
RECII', ID ,:21-0069675
-,....-. .- -.
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I'ROVIDRR'NAHR
DATES OF SERVICE
MA AMOUNT
Milton S. Hershey ~I,C,
INPATIENT.
OUTPATIENT
5-6-9~ to 5-]1-9~
5-]8-93 to 6-15-93
13,435,95
3]7.50
HMC-Orthopedic Sur~ical
HMC-Radiology Department
5-3-9~ to 8-31-93
471,7.5
5-(,-93 to 6-15-93
599,50
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COIDIOHWJ:4L'lH or .DlNSYLVANIA
DUAR'nIDT or .U8LIC WELrARE
orrlCE or ADMINISTRATION
T.L - CASUALTY UNIT
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LAW OffiCES
~__]ir.~,~_,..,?\;ino"-~
ZEIGLER 8( ZIMMERMAN, P.C.
355 N, 21ST STREET. SUITE 304
P,O, BOX 1080
CAMP HILL. PA 11011,3101
PAUL L, ZEICLER
BARBARA A, ZIMMERMAN
MARCARET M, YENKOWSKI
(717) 73101484
JOHN C. BECKER
OF COUNSEL
FAX
111n 13101408
September 14, 1994
The Honorable Harold E. Sheely
President Judge
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
REI Debra Puzzo, a minor by Daniel A. Puzzo an4 Jene14a
Puzzo, her parents an4 natural guar4ians, an4 Daniel A.
Puzzo an4 Jene14a Puzzo, in their own rigbt v. Hiobelle
Askins
No. 94-1882 civil Term
Dear Judge Sheely:
with regard to the above-noted matter, please find the
following as per your instructions:
,
1. a copy of a variable rate Certificate of Deposit setting
forth a restriction for withdrawal upon Court Order, in
the amount of $14,094.87;
2. an acknowledgement letter of full payment of the monies
due the Department of Public Welfare, said amount being
$9,982.13; and
3. copies of record of payment with correspondence and
attached bills for:
a. Kreamer Medical - $270.00
b. Kearns and Ashby, DDS - $137.00
c. West Shore Advance Life Support Services - $250.00
d. Silver Spring Ambulance & Rescue Assoc. - $125.00
Please also be advised that there was $140.00 withdrawn for
payment of a dentist bill that regarded services in the month of
August, 1994.
PLZ/kam
Enclosure
er
The Honorable Harold E. Sheely
September 14, 1994
paqe Two
I am advised by all appropriate medical providers that the
above payments are satisfactory and that, in fact, there are no
other medical payments due with reqard to this accident.
To summarize, therefore, there was $25,000.00 received from
which the followinq deductions were made:
$25,000.00
- 9.983.13
15,016.87
270.00
14,746.87
137.00
14,609.87
250.00
14,359.87
125.00
14,234.87
140.00
$14.094.87
with reqard to the under insurance aspect of this case, we are
continuinq to discuss the matter with the Puzzo's and Ohio
Casualty. I will advise the Court when that matter has been
resolved.
cc: Mr. and Mrs. Daniel Puzzo (w/o encl.)
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CDMMDNWEALTH OF PENNSYLVANIA
DEPARTMENT DF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION . CASUALTY UNIT
P.D. BDX 8488
HARRISBURG. PA 17105
'Aua ! - 1994
July 29, 1994
Paul zelgler Esq
355 North 21st Street
Suil:e 304
Camp Hill PA 17011
REI Puzzo, Debra
CIS. 750120583
C/R. 21-0069675
Date of Injury. 5/06/93
Dear Attorney Zeigler,
This is to acknowledge receipt of your payment in the amount of
S9,98J.1J regarding the above-named individual, a recipient of medical and/or
cash assistance.
Your cooperation in resolving this matter is appreciated,
S~~~:~ IH J
i;!,'!;.s II~
Claims Investigation Agent
(717) 772-6725
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MkMk^ ^, ZIMMEkMM'
M^kC^kn M, YENKOIIVSK'
US^ C. K^TTU,M^N.
(711) 731.1404
JOliN C, BECKE..
or COUHUl
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-AUO ADMUIID 10
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July 25, 1994
Kreamer Medical
19 S. Market street
Elizabethtown, PA 17022
RB: puzzo, Debra
Claim No.: 930178195
Date ot Service: 5/11/93
Znvoice No: 697-8255
Gentlemen:
Please find enclosed a draft, made payable to Kreamer Medical,
in the amount of $270.00 which represents payment in full in regard
to services rendered concerning the above-noted individual
Thank you for your patience in this matter.
yours,
PLZ/kam
Enclosure
cc: Mr. and Mrs. Daniel Puzzo
Dana M. Harris, Sr. Claims Represent~tive
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t
nt.MlnANCE ADYtCE
-QEGOTIABLE
AECO~~~.~U.TACCOUHTPAYMENT.
FDR'" NO. ATAll-OPD
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K~(\I'IE~ 11EDICAL
19 S..MARKET ST.
ELIZA9ETHTOWN, PA 17022
717-367-12&2
PROVIDER IDI KR2S2929
STATEMENT
Pagel
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8111101110111 u...d: 07/29/93
^(;r;r~1I11 Nil: 697-ll255
AIltOllll1 Paid ___.__.
NmlE
INBur<ANCE
DP002250654
OHIO CASUALIYY...
ATTN I J'OHN L YTEr<
PO BOX 843
CARLISLE, PA 17013
PUZZO, DEBRA
3326 LOCUST POINT RD
MECHnNICSBURG, PA 17055
m.I,. DII..LHIG lTEI'IS
'.I,~."...,:'~.J--'- Onto lIemNo, - 1=-- -_-- 1}"l"lil,lhlll -. _r ~ CI~~II;_~'~; i. _.PnVlllenl& -L~~1~~I,'~:~
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J8278 05/11/93 E0135 WALKER,FOLD,ADJ'. 21.55 0.00 21.55
102711 05/11/93 E1150 W/C DET AIVSW DET LEG RE 76.013 0.00 76.00
18100 05/11/93 E1150 W/C DET AR/SW DET LEG RE 76.00 0.00 76.00
111HJ0 ~)5/ 11/93 E0135 WnLKER,FOLD,ADJ'. 85.00 0.00 85.00
18279 06/11/93 E0135 WALKER,FOLD,ADJ'. 21.55 0.00 21.55
Ill;~20 06/11/93 E1150 W/C DEl' AR/SW DEl' LEG RE 76.00 0.00 76.00
PER JOHN LYTER AT OHIO CASUALITY, YOUR INSURANCE IS EXHAUSTED.
PAYMENT IS THEREFORE YOUR RESPONSIBILITY.
WE MUST RECEIVE YOUR PAYMENT IN FULL BY AUGUST 14. 1993
THANK YOU
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II Accounl Boll1nce
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.-~,'[ 35~.~a L_~~0!, I356~ ~0
DAYS PAST DUE
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97.~~
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60 - 89 90+
258;55- .., ..-----..-0;'00
1 TOTllLDUE
---- 356; 10
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OnlCml^1. ' r:un youn nFCOl1nS
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ZeiGLeR & ZIMMeRMAN, p.e,
J!\!\ N. 21ST StR.Ut. ~UIIF. 30'"
r,o hOX lonn
C^Mr IlIll. I'^ 11011.3101
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ell1) 7.:111<111"
JOliN C, BECkE...
or COUtUfL
.^UO ;;;:;;;..n .0
NI. JIIUIY IIAIl
r^UL L. ZEICLeR.
n^,U'^R^ ^. ZIMMERMAN
MARC^,lEl' M. YENKOWSKI
USA C. KArl ERMAN-
ell1>> 131-1"'M
July 25, 1994
Kearns and Ashby, DDS, P,C.
4836 E. Trindle Road
Mechanicsburg, PA 17055
REI Puzzo, Debra
Claim No.1 930178195
Date of servicel 5/11/93
Invoice NOI 6569
Gentlemen:
Please find enclosed a draft, made payable to Kearns and
Ashby, DDS, pc, in the amount of $137.00 which represents payment
in full in regard to services rendered concerning the above-noted
individual
Thank you for your patience in this matter.
yours,
PLZ/kam
Enclosure
cc: Mr. and Mrs. Daniel Puzzo
Dana M, Harris, Sr. Claims Representative
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AECOlm-OJ. IIIUsr ACCOUNT 'AYMINTS
FORM NO. AT A6-0rD
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Kearns and Ashby, DDS, pr
4836 E, Trindle Road
n",dlanicsburg, PA 17055
717-737-5834
(
J- OATI
9/16/93
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6569
)
Patient te, bill
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F'a ti ent
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Dolnl.)l PU7.7.0
)]/;0 Locust Poi lit r,oad
nf)bra Puzz,:,
:~3/;o Locust r'.;. i nt Road
t'U::CHANIC SE3lJHG, PI~
l70~,5
~lECH,'NICS8UR"., PA
l70f,S
.j! - bU. '--r, '-';/O---":T1--= -1 20---u~r::'')
137.00 ,00 .00 ,00
o a
137.00
u - .JV
.00
_._.~-_._.._- --- -- ..-----..-".".-
Date
Tooth ~,ur face
P'I)C
Code>
Descr J pl.. J 'In
Amount
-----.-----.-------
CUI'rent. b,)l","o:C.'
137.00
Prompt attention to your ovor-
clue balance is appreciated,
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3!\!i H. ;lIS1- SIRE!1. SUIlF. ]Oot
r,o. bOX lono
C^Mr IlIll. r^ 17011.3101
MUL L. UICU"
nAIUIAR.^ ^. ZIMMERMAtI
MAJlCAI\I!T M. YENKOWSKI
LISA c. KArrf.RM^,l.
(117) 73.....04
JOliN C. aECKE"
or coutun
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(71n 731-1"0"
.AUO ;;:;;;..n fO
HI" JrUIY BAa
July 25, 1994
West Shore Advanced Life
support Services, Inc.
503 North 21st Street
Camp lIill, PA 17011-2204
REI puzzo, Debra
Claim No.: 930178195
Date or servioe: 5/11/93
Invoice NOI 9305088-1
Gentlemen:
with regard to the above-noted matter, enclosed planse find a
draft made payable to the West Shore Advanced Life Support
services, Inc, in the amount of $250.00 which represents full
payment for the charges rendered.
Thank you for your patience in this matter.
yours,
er
PLZ/kam
Enclosure
cc: Mr. and Mrs. Daniel Puzzo
Dana M. Harris, Sr. Claims Representative
II
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CHECK CASE
OATE .. . . ISSUED TO NUMBER ' NUMBER
I !JII( Itv.~m. Odt'tUlqef ~f~' 1/09/ l1'tJ1:~~O
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A.l.tOIJNI
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-&GO-TIABLE
RICORD 0' TRUST ACCOUNT PAYMENTS
FDRM NO, ATA5-BPD
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INVOICE
,
as WEST SHDRE "-
ADVANCED LIFE SUPPORT SERVICES, INC,
&03 North 21" SlfMI . Clmp HIli, PA 17011.nG4 . t117' 161-'038
nDlML ID ,1I.uuoaJ
INVOICE II: ( '1305060-1)
DATE: C_ 05/14/93)
BILL TO:
I'IIIZO ,Il[l.\HA
J~:~ LO~U51 rulNl RU
l'lLo;IIANICSISLIIW.PA 1/055
PATIENT: P1I7Z0,I.JJI'.I/^
:lJfti 1l1l:II',1 POINT IW
I'I[CIIANIC',I~IIIW,PA 17055
ACCOUNT II: PA 1-0061 17
POLICY NAME:
INS. II:
INS. II:
TRIP II: ~'JlJ:"1I11l DATE OF SERVICE: 05/11/93
PATIENT PICKED UP: SCINE ur LMCllUl:Nn
PATIENT TAKEN TO: 1351-~1. S. IIEl/Sllrr HUJlCAl. ~rNIER:IIERSlIlY, 1"\ 17033
DESCRIPTION OF ILLNESSIINJURY:
1100Y-TRAUMA, MULTIPLE SY51LH5
9106-CLOSED IIEAD -I RAUMA
OGO-TRAUMA. ABDOMINAL
DESCRIPTION
ALS SQUAD,NON-TRANSPORTING
INf RING LACTATE 1000CC
ANGIOCATH (14-24)
IV EXT TUBING
UNIT COST orv, AMOUNT DUE
20!). !i5 01 285,55
!i.l1 02 10.22
11.111 03 12.42
li.CJO 02 13.60
R~G\\JVE[J
JUn J. ;.19"
Hf-\Hi'i G:8ltRG
CLAIr!. '; DEPT.
COMMENTS: Pl.EASE rUT ACCOUN r " ON CHlCK.
WSALSS, INC. IS A NON-THANSPOIHING PAnAMEllIC
UNIl. CIIAnGES ARE IN ADUII ION 10 ANY LOCAl.
AHKULANCE SEnVICE rrrs.
SUBTOTAL
AMOUNT
PAID
TOTAL
321 9
THANK I'OU
371.99
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ZeiGLeR ~ ZIMMeRMAN, P.C.
J!".!\ u. ;tl~r !'o1l\frr. ~1I11r: ;\0.1
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CAMr IIILl. r^ 11011.31111
MUL L. ZEICLE...
BARBAR^ ^. ZIMMERMAN
MMlC^I\ET M. yeNKOwSKI
L1S^ c. K^-rll:RMAW.
elll) 731.I<1fM
JOliN C, IECKE'"
or COUN51!L
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NrwJIUI""'''
July 25, 1994
silver spring Ambulance &
Rescue Association
P. O. Box 177
New Kingstown, PA 17072
RE: puzzo, Debra
claim No.1 930178195
D/rl 5/06/93
Gentlemen:
Enclosed please find a draft made payable to Silver spring
Ambulance & Rescue Association in the amount of $125.00 which
represents payment in full in regard to services rendered
concerning the above-noted individual.
Thank you for your patience in this matter.
yours,
PLZ/kam
Enclosure
cc: Mr. and Mrs. Daniel Puzzo
Dana M. lIarris, Sr. Claims Representative
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S i 1 ver Spl" i I1g Amb ~ Res Assn
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:15'\ N. ;r1sr St'I\I!ET. SUITE 3001
r.o. 80)( 1080
CAMP HILL. r^ 11011.3107
MUL L. ZEICUR
MRMR^ ^. ZIMMERt.MN
M^RC^Il.ET M, YENKOW'KI
LISA M. KArTERMAN.
(111) 731.1110"
JOliN C. BECKER
or COUNUL
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tAUO ADMlrrlD 10
Nt.. Jlun IAk
August 17, 1994
Hr. & Mrs. Daniel Puzzo
336 Locust Point Drive
Hechanicsburg, PA 17055
REI Debra Puzzo v. Michelle Askins
Our File NOI 93-1123
Dear Hr, & Mrs. Puzzo:
As per our discussion, enclosed please find a draft made
payable to Kearns and Ashby for dental work required by virtue of
the automobile accident in the amount of $140.00.
Please also be advised that a savings account has been
established at the Pennsylvania National Bank with the principal in
the amount of $14,094.87. I will forward the bank book to you
under separate cover.
-
eigler
I
PLZ/kam
Enclosure
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Public Welfare and Daniel A. Puzzo and Jenelda Puzzo are hereby
appointed custodians of the remaininq proceeds from the Twenty-five
Thousand ($25,000.00) Dollar settlement.
3. Daniel A. Puzzo and Jenelda Puzzo shall promptly
submit proof that outstandinq medical bills have been paid (throuqh
presentation of receipts or copies of receipts to the court) and
that the proceeds received for their dauqhter have been placed in
a federally insured account in a bank or savinqs association
orqanized under the laws of the Commonwealth of Pennsylvania, for
the purpose of maintaininq the funds in said account until Debra
Puzzo attains her 18th birthday on Auqust 5, 2004 (said proof to be
presented throuqh oriqinal or copy of bank documentation). Said
account to be marked to indicate that no withdrawal is permitted
without prior Order of Court before Auqust 5, 2004.
4. Daniel A. Puzzo and Jenelda Puzzo shall be permitted, only
after first obtaininq court approval, to invade first the income
and then the principal of the settlement proceeds for the
reasonable needs of Debra Puzzo arisinq from the physical and
emotional injuries she sustained.
5. The court retains the riqht to require accountinq(s) by
Daniel A. Puzzo and Jenelda Puzzo at any time until the date of
Debra f/uHo' s' 'l8i:h birthday on Auqust 5, 2004.
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BY THE COURT:
M, HJ $2 C ~I A~H
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DEBRA PUZZO, & miDor, ~y
DANIEL A. PUZZO &D4 JBNELDA
PUZZO, her pareDts &D4
Datural quar4iaDs, aD4
DANIEL A. PUZZO aD4 JBNBLDA
PUZZO, iD their own riqht,
PlaiDtiffs
IN THB COURT OV COMMON PLEAS
CUMBERLAND COUN'l'Y, PENNSYLVANIA
CIVIL ACTION - LAW
v.
NO.1 ,~ _ IniJ.
(J"Y'I'L TUn?
MICHBLLB ASKINS,
DefeD4aDts
ORDBR
AND NOW, this I!/.-~ay of , 1994, it is
hereby ORDBRBD that a hearing be held for consideration and
approval of the within Petition for
Settlement.
Said hearing shall be held
, 19~at J :(/(J
~, Cumberland County
Court Approval of a Minor's
on the &- -I-IJay of
o'clock ~.M. in
P7,11t '1
Courtroom No.
Courthouse,
Carlisle,
Pennsylvania.
BY THE COURT:
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Commonwealth of Pennsylvania
County of Cumberland
Debra Puzzo, a minor. by
Daniel A. Puzzo and Jenelda
Puzzo, her parents and natural
guardians, and Daniel A. Puzzo and
Jenelda Puzzo, in their own right
Court 01 Commoll Pleas
94 - 1882 Civil Term
19____
No.
-------------------------------------
vs.
In ___~~~!~_~~~~~:~______________________
Michelle Askins
336 Locust Point Road
Mechanicsburg, PA 17055
Michelle Askins
1:0 _____________________________________________
You are hereby notified tha t
Debra Puzzo. a minor, by Daniel A. Puzzo and Jenelda Puzzo, her parents and natural
g'i';'mfii"ii;-aiia-DaiiTeI"X;-Pilz-iO-Bild-jenEilaa--Plizzo;-lii-ffieTi-CMi-rl'gnt---------------
the Plaintiff ha s commenced an action in ___~_:l.Y!L~__________________________________________
against you which you are required to delend or a default judgment may be entered against you,
(SEAL)
Lawrence E. welker
.------------------p~th~~~t;;y------------------
Date ___!\R:~}.__~~_________________ 19.?.~_
By ___ Q. U:.~--lJJ..~--&l1kW-7.~ '-:'.'__
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DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JENELDA
PUZZO, in their own right,
Plaintiffs
IN THE COURT OF COKMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. :
q4 - 1~8~
Civil TUNl
v.
MICHELLE ASKINS,
Defendants
WAIVER OF SERVICE AND APPEARANCE
I accept service of the Writ of Summons on behalf of Defendant
Michelle Askins, consenting to the jurisdiction of the court and
waiving service of process.
Defendant.
I also hereby appear on behalf of
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METZGER, WICKERSHAM, KNAUSS & ERB
Dy~,,~L~~--,/LQ,-~~cZ,
Jered-u;-nock, Esquire
Attorney I.D.No. 19211
Attorney for Defendant
P. O. Box 93
Harrisburg, PA 17108-0093
(717) 238-8187
Dated: March 22~ 1994
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ZEIGLER ~ ZIMMERMAN. P.C.
35514, 21ST STREET. SUITE 304
P,O BOX 1080
~MP HILL. P^ 17011.3707
PAUL L. ZEIGLER
BARBARA A. ZIMMERMAN
(117) 131.1484
JOHN C. BECKER
Of COUNSEL
'AX
(711) lJI.14Q8
October 23, 1995
The Honorable Harold E. Sheely
President Judge
Cumberland County Courthouse
One Courthouse square
Carlisle, PA 17013
RBI Debra Puzzo, a minor by Daniel A. puzzo and Jenelda
Puzzo, her parents and natural guardians, and Daniel A.
Puzzo and Jenelda Puzzo, in their own right v. Michelle
Askins
No. 94-1882 civil Term
Dear Judge Sheely:
with regard to the above-noted matter, enclosed please find a
copy of a deposit slip reflecting that the $4,800.00 initial
payment under the Court approved Agreement has been deposited in
the existing variable rate certificate of Deposit which previous
have funds have also been depo ited.
ly yours,
PLZ/kam
Enclosure
cc: Mr. and Mrs. Daniel Puzzo
Douglas B. Marcello, Esquire
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lAW OFFICES
Z~lQL~R l!f ZlMM~RMArt. P.C,
355 N, 2'ST STREET. SUITE 304
P.O. BOX 1060
CAMP Hill. PA 11011,3101
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The Honorable Harold E. Sheely
President Judge
Cumberland County Courthouse
One Courthouse Square
CarliSle, PA 17013
17013-3322 23
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DEBRA PUZZO, a minor, by DANIEL A,
PUZZO and JENELDA PUZZO, her parents
and natural guardians, and DANIEL A,
PUZZO and JENELDA PUZZO, In their own
right,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNlY. PENNSYLVANIA
CIVIL ACTION. LAW
Plaintiff
No, 94.1882 . Civil Term
v.
MICHELLE ASKINS,
Defendant
PETITION FOR COURT APPROVAL TO RELEASE FUNDS
WHEREAS, Petitioners are DEBRA PUZZO, a minor, by DANIEL A. PUZZO and
JENELDA PUZZO, her parents and natural guardians, and DANIEL A. PUZZO and JENELDA
PUZZO, in their own right, residing at 180 Ash Avenue, Woodstock, Illinois, 60098,
WHEREAS, Debra Puzzo Is a minor residing at 180 Ash Avenue, Woodstock, illinois,
60098, under the care of her parents and natural guardians, Daniel A. Puzzo and Jenelda
Puzzo,
WHEREAS, Debra Puzzo, a minor, Is the beneficiary of funds for an auto accident
suffered May 6, 1993, when Debra Puzzo was struck by an automobile driven by the Defendant.
(A copy of the setUement agreement with Ohio Casualty Company Is attached hereto as "Exhibit
A.")
WHEREAS, by order dated July 26, 1995, the Honorable Harold E. Sheeley approved a
settlement with the Defendant's automobile Insurance carrier, Ohio Casualty company to settle
the underinsurance claim for a lump sum of $5,000, and four annuity payments of $5,146,34
commencing August 5, 2004, and ending August 5, 2007, the disbursement of which Is to begin
at the age of Debra Puzzo's majority. (A copy of that Order Is attached hereto as "Exhibit B,")
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WHEREAS, the lump sum of $4,800,00, or $5,000 less attomey's fees of $200, was
deposited Into a restricted bank account with Pennsylvania NaUonal Bank under account
number 888-35898, which funds are to be made available to Debra Puzzo upon reaching the
age of maJority, othorwlse by Order of this Court, (A copy of the deposit slip is attached hereto
as "Exhibit C,")
WHEREAS, Daniel A. Puzzo and Jenelda Puzzo as parents and natural guardians of
Debra Puzzo, a minor, are authorized to execute any documents necessary pertaining to this
matter,
WHEREAS, Debra Puzzo, a minor child, has the opportunity to travel to Germany for an
educational opportunity sponsored through her high school,
WHEREAS, Debra Puzzo, a minor child has requested release of the funds from the
restricted bank account to finance the purchase of this trip; otherwise, Debra Puzzo would not
be able to attend. (A copy of Debra Puzzo's request and consent of the release of funds Is
attached hereto as "Exhibit D,")
NOW THEREFORE:
1. The Petitioners are In favor of granting child's request for release of funds in the
amount of $3,000 plus attomey's fees to finance the trip to Germany, plus
attomey's fees to obtain these funds, the costs of which are Itemized In "Exhibit
E," attached hereto.
2, The proposed trip to Germany Is an educaUonal trip and in the best Interests of
Debra Puzzo, a minor,
Daniel A. Puzzo
-
VERIFICATION
WE, Daniel Puzzo and Jenelda Puzzo, parents and natural guardians of Debra
Puzzo, a minor. have read the foregoing Petition for Court Approval to Release Funds and
hereby affirm that It Is true and correct to the best of our personal Information, knowledge and
belief, This Verification and statement Is made subject to the penalties of 18 Pa, C,S, 4904
relating to unswom falsification to authorities, We verify that all the statements made In the
foregoing are true and correct and that false statements may subject us to the penalties of 18
Pa. C,C, ~ 4904,
DATE: VXfJ h ~tJ3
~~1J: 6J7fI6r
Jen a Puzzo
,
3, The proposed trip to Germany Is an appropriate use of the funds for the minor
child,
4, The minor child has appropriately requested these funds,
WHEREFORE, Pelilioner respectfully requests that thIs Court release the funds In the
amount of $ 3400 (est.) ,which represents costs for the educational trip and attorneys'
fees,
Respectfully Submitted,
BARBARA A. ZIMMERMAN,. P,C.
By:
"
arbara A, Zlmme
Supreme Court I~ 0, 50572
355 N, 21"1 Stree , Suite 201
Camp Hili, PA 17011-3707
Attomeys for Plaintiff
(717) 731-1484
DATED: May 7, 2003
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SETTLEMENT AGREEMENT AND RELEASE
This Settlement Agreement and Release ("Settlement Agreement")
is entered into by and among the following parties: Deborah Puzzo, a
minor, by and through Daniel Puzzo and The Ohio
Casualty Insurance Company (hereinafter collectively referred to as
"the parties"). "Claimant" shall collectively mean Deborah Puzzo, a
minor, by and through Jenelda Puzzo and the heirs,
executors, administrators, personal representatives, successorS and
assigns of same; and "Insurance Company" shall collectively mean The
Ohio Casualty Insurance Company and the successors and assigns of
same.
I. RECITALS
A. On or about May 6, 1993, Claimant sustained personal and
physical injuries as a result of the alleged tortious conduct of an
underinsured tortfeasor, all of which is hereinafter referred to as
the "Occurrence". In connection with the Occurrence, Claimant has
asserted a claim against Insurance Company in accordance with the
underinsured motorist coverage provision of Claimant's policy with
Insurance Company.
B. The parties desire to enter into this Settlement Agreement
to provide, among other things, for certain payment(s) in full
settlement and discharge of all claims and actions of Claimant
against Insurance Company for damages arising out of or due to the
Occurrence, on the terms and conditions set forth herein.
NOW THEREFORE, it is hereby agreed as follows:
II. RELEASE
In consideration of the lump sum payment set forth herein and
the promise to make the periodic payment(s) set forth herein,
Claimant hereby releases and forever discharges Insurance Company
from any and all past, present or future underinsured claims for
damages for personal and physical injuries which Claimant has or
claims to have against Insurance Company, for or in any manner
arising out of the Occurrence. This release and discharge shall be
a fully binding and complete settlement among all parties to this
Settlement Agreement. This release is entered into in settlement of
an under insured motorist claim arising out of the Occurrence.
III. UNKNOWN INJURIES
Claimant fully understands that Claimant may have suffered
personal and physical injuries that are unknown to Claimant at
present and that unknown complications of present known injuries may
arise, develop or be discovered in the future, including, but not
limited to, subsequent death or disability. Claimant acknowledges
that the consideration received under this Settlement Agreement is
intended to and does release and discharge Insured and Insurance
Company from any claims for, or consequences arising from, such
injuries and the Occurrence/ and Claimant hereby waives any rights
to assert in the future any claims not now known or suspected even
though, if such claims were known, such knowledge would materially
affect the terms of this Settlement Agreement.
IV. PAYMENT(S) TO CLAIMANT
A. Lump Sum. Claimant has received Five Thousand Dollars and
No Cents ($5,000.00), receipt of which is hereby acknowledged.
B. Periodic Payments. Insurance Company hereby agrees to make
the following annual payments to Deborah Puzzo. The sum of Five
Thousand One Hundred Forty-Six Dollars and Thirty-Four Cents
($5,146.34) per year, shall be payable to Deborah Puzzo commencing
August 5, 2004, and shall continue through August 5, 2007 (four (4)
annual payments). If Deborah Puzzo dies before August 5,2007, the
payments set forth in this Paragraph IV.B shall be made as due to
, upon proof of death being furnished to
Insurance Company, or to such other beneficiary or beneficiaries as
Deborah Puzzo shall designate, in writing, after reaching the age of
majority and prior to her death, to Insurance Company. No such
beneficiary designation or revocation thereof shall be effective
unless it is in writing and delivered to Insurance Company.
C. Nature of Payment(s). All sums paid to Claimant pursuant to
this Settlement Agreement constitute damages on account of personal
injuries or sickness, in a case involving physical injury or
physical sickness arising from the Occurrence are intended to fall
within the meaning of Sections 104(a) (2) of the Internal Revenue
Code of 1986, as amended.
V. FINANCING OF PERIODIC PAYMENT OBLIGATION
A, Insurance Company as Obligor. Insurance Company shall, at
all times, remain directly responsible for the continuing obligation
of making all periodic payment(s) set forth in Paragraph IV.B.
Insurance Company's duty to make such periodic payment(s) shall at
all times be, and is, an unfunded and unsecured obligation to pay
money to Claimant in the future and Claimant can rely solely on the
general credit of Insurance Company for collection of the payment(s)
2
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set forth in Paragraph IV.B. Insured has no duty to make such peri-.
odic paymentls).
B. Third Party Payment. It is understood and agreed by the
parties that, as a means of providing a source of funds for Insur-
ance Company to satisfy its obligation to make periodic paymentls)
to Claimant pursuant to this Settlement Agreement, Insurance Company
will purchase, for its own investment purposes, an Annuity Contract
from The Ohio Life Insurance Company lthe "Annuity Contract")
immediately upon execution of this Settlement Agreement. Insurance
Company shall be the owner of the Annuity Contract and shall have
and retain all rights of ownership in the Annuity Contract. For its
own convenience, Insurance Company shall direct The Ohio Life
Insurance Company to make the periodic paymentls) directly to the
respective payees designated in Paragraph IV.B. Such paymentls)
will be applied against the obligation of Insurance Company to such
payees, as set forth in this Settlement Agreement.
C. Status of Claimant. Claimant acknowledges that Claimant has
no right to receive the present value of the paymentls) due Claimant
pursuant to Paragraph IV.B, or to control the investment of, or
accelerate, defer, increase or decrease the amount of any paymentls)
required to be made to Claimant. Claimant shall only be entitled to
receive the paymentls) specified in Paragraph IV.B when due.
VI. NONASSIGNMENT BY CLAIMANT
The periodic paymentls) to be received by Claimant pursuant to
this Settlement Agreement are not subject in any manner to
anticipation, alienation, sale, transfer, assignment, pledge or
encumbrance by Claimant.
VII. ADEQUATE CONSIDERATION - DENIAL OF LIABILITY
Claimant agrees and acknowledges that Claimant accepts
payment(s) of the sums that Claimant is to receive pursuant to this
Settlement Agreement as a full, complete, final and binding
compromise of matters involving disputed issues regardless of
whether too much or too little may have been paidl that paymentls)
of the sums to Claimant shall not be considered admissions by any
party hereto of any liability or wrongdoing 1 and that no past or
present wrongdoing on the part of any party shall be implied by any
paymentls).
VIII. ENTIRE AGREEMENT
This
Claimant
herein.
Settlement Agreement contains the
and Insurance Company with regard
There are no other understandings
entire agreement between
to the matters set forth
or agreements, verbal or
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, btherwise, in relation thereto, between the parties except as herei.n
expressly set forth.
IX. READING OF AGREEMENT
In entering into this Settlement Agreement, Claiman~ represents
that Claimant has completely read all terms hereof and that such
terms are fully understood and voluntarily accepted by Claimant and
that Claimant has been adequately represented, or has had
opportunity to seek representation, by counsel of Claimant's choice.
X. TRUST OBLIGATION
Claimant agrees to take, through any representative designated
by Insurance Company, such action as may be necessary or appropriate
to recover damages suffered by the Claimant in the Occurrence from
any person or organization who may be legally liable therefore.
Claimant agrees to hold any monies recovered by Claimant from such
person or organization in trust and paid first to Insurance Company
to the extent of the payment(s) set forth in Exhibit A plus the
amount incurred by Insurance Company for expenses, costs and
attorney fees in connection with the recovery of such monies!
provided, however, any monies remaining after such payment to
Insurance Company shall be retained by the Claimant.
XI. SUBROGATION
Claimant hereby assigns and transfers to Insurance Company each
and all claims and demands that Claimant has against any other per-
son, firm, property or corporation, arising from or connected with
the Occurrence! and Insurance Company is hereby subrogated in
Claimant's place and to Claimant's claims and demands and Insurance
Company is hereby authorized and empowered to sue in Claimant's name
or otherwise.
XII. FUTURE COOPERATION
Claimant covenants that Claimant has not released or discharged
any claims or demands arising out of the Occurrence and that
Claimant will assist and cooperate with the representative
designated by Insurance Company to recover damages suffered by
Claimant. Claimant further agrees to execute any and all
supplementary documents and to take all additional actions that may
be necessary or appropriate to give full force and effect to the
terms and intent of this Settlement Agreement which are not
inconsistent with its terms and which may be necessary to recover
such damages.
4
I
,..' XIII.
INDEMNIFICATION
In further consideration of the payment(s) and the promise to
make ,future periodic payment(s) set forth herein, Claimant agrees to
indemnify and hold harmless Insurance Company and all parties .
released against any and all medical or other liens, or claims that
are, have been in the past, or may be in the future asserted against
anyone as result of the aforesaid Occurrence.
XIV. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT
This Settlement Agreement has been negotiated by the parties.
Claimant warrants, represents and agrees that Claimant is not
relying on the advice of Insurance Company, its counsel, or anyone
associated with Insurance Company as to the legal and income tax or
other consequences of any kind arising out of this Settlement
Agreement. Accordingly, Claimant hereby releases and holds harmless
Insurance Company and any and all of its counselor consultants from
any claim, cause of action or other rights of any kind which
Claimant may assert because the legal, income tax or other .
consequences of this Settlement Agreement are other than those
anticipated by Claimant.
XV. COURT APPROVAL
Claimant represents that Claimant has received any and all
necessary court approvals to enter into this Settlement Agreement.
XVI. CONTROLLING LAW
This Settlement Agreement shall be construed and interpreted in
accordance with the laws of the nia.
Dated: ~ /~ /'11.5
.Ii
through Daniel Puzzo
Dated:
Puzzo
'da..
De Puzzo,
Jenelda Puzzo
The Ohio Casualty Insurance Company
and through
By:
Title:
5
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RELEASE OP CLAIMS
For and in consideration of the payment to us of the sum
of Fifteen Thousand Dollars ($15.000.00), we, Daniel Puzzo and
Jenelda Puzzo, individually and as parents and natural guardians of
Debra Puzzo, a minor ("Releasers"). do hereby release and forever
discharge Ohio Casualty Insurance company, its parent and
subsidiary
companies,
agents,
officers,
employees
and
representatives, of and from any and all actions, causes of action,
claims, demands, damages, costs, loss of services, expenses,
compensation, consequential damage, uninsured motorist claims,
under insured motorist claims 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 6th day
of May, 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
corporations hereby released by whom liabillty 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 Ohio Casualty 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,
It is further agreed that I will indemnify and hold
harmless Ohio Casualty Insurance Company, its parent and subsidiary
company, officers, agents, employees, insurers, assigns, and
representatives from anyand all liability arising from liens and/or
subrogation claims including any compensation or medical payments
due or claimed to be due under the law, state or federal regulation
. ' I
~
or contract.
We expressly acknowledge that all obliqations to
satisty such liens are that ot releasor not releasee.
We certity that we are over eighteen (18) years ot aqe,
that we are the parents and natural guardians ot Debra puzzo, a
minor, and we turther state that we have caretully read the
toregoing Release and know the contents thereot and we signed the
same as our own tree acts and intending to be legally bound
thereby.
seals this
IN WITNESS
'f"A-
19 day
WHEREOF, we have hereunto set our hands and
ot -1l1l$/ld-
, 1995,
WITNESSETH:
D
~e&/'(J tJ}, n;:~(SEAL)
J elda puzzo, paren d natural
guardian ot Debra Puzzo
Sworn to and subscribed
betore me this 19Y~
day of A'1"s.f-
,
1995.
x~-;~~ ~~
My commission expires: In,!, 11119("
.MR_
ftJIf~ K PAGm. /IIlary J\jllllc
lIlIdwIic:aIlClll. (;uml';:iIlIol CIlI~l
~1oJoII Dcpil&AIlQ. " ,.
S::vhlhlt a
JUL 2 e 1995
DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JENELDA
PUZZO, in their own right,
Plaintiffs
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNT~, PENNS~LVANIA
V.
MICHEI,LE ASKINS, CIVIL ACTION - LAW
Defendant NO. 94-1882 CIVIL TERM
IN RE: MINOR'S SETTLEMENT
BEFORE SHEEL~. P.J,
MEMORANDUM OPINION AND ORDER OF COURT
A hearing was held today on a petition of the
Plaintiffs to approve a settlement with Ohio Casualty Company,
their underinsurance carrier, I had previously approved a
settlement with the Defendant's insurance company, and at the
hearing today I heard the testimony of Mrs. Puzzo who indicated
that Debra has not had any problems since we had our original
hearing in May of 1994 as a result of the injuries in this case.
They have now reached an agreement with ohio casualty
Company to settle the underinsurance claim, and the agreement is
that a lump sum payment of $5,000,00 will be payable to the
parents, and from that sum of $5,000.00 I will authorize $200.00
of that to be paid to counsel for the Plaintiffs for his
appearance in court today and for preparation of the petition,
The balance of $4,800.00 shall be deposited in an
existing, restricted account that was opened after the hearing
in May of 1994, and this money shall be subject to the same
terms and conditions as previously set forth.
In addition Ohio Casualty will make four payments of
$5,146.34 commencing August 5th, 2004, and ending August 5th,
2007. Mrs. Puzzo indicates that this has been discussed and is
agreeable to she and her husband, and, therefore, I will sign
the order authorizing the settlement of this action with their
underinsurance carrier for the terms above set forth.
It was brought to my attention also that the above
four payments shall be paid by the Ohio Life Insurance Company.
By the Court,
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Zeigler, Esquire
Plaintiffs
NAY 1 9 1994
DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JENELDA
PUZZO, in their own right,
Plaintiffs
. IN rHE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
MICHELLE ASKINS, CIVIL ACTION - LAW
Defendant NO. 94-1882 CIVIL TERM
IN RE: MINOR'S SETTLEMENT
BEFORE SHEELY, P,J.
MEMORANDUM OPINION AND ORDER OF COURT
A hearing was held today on the petition to approve
the compromise settlement in the above-captioned case. The
Court is satisfied from hearing the testimony of the minor's
mother that apparently she has recovered from the injuries
sustained in this accident except the mother did indicate that
there may have to be something done with some bottom teeth, and
that will have to be resolved in the future.
The petition alleged that the maximum limit of
coverage of the Defendant in this case was $25,000.00, and the
Defendant's insurance company has agreed to pay that sum in
settlement of the above claim,
At the hearing today we heard that the Plaintiffs' own
insurance carrier, Ohio Casualty, apparently is proposing to pay
the Plaintiff an additional $lS,OOO.oo from the underinsurance
coverage on their policy, That has not been made definite at
this time, but in the future Ohio Casualty will be pay that sum.
The Court will sign a release accordingly, and the
Court would direct that should that be the case, that the
puzzo's, as natural guardians of Debra, are authorized to
receive that money provided that it is also deposited in an
Public Welfare and Daniel A. Puzzo and Jenelda Puzzo are hereby
appointed custodians of the remaining proceeds from the Twenty-five
Thousand ($25,000,00) Dollar settlement.
3. Daniel A. Puzzo and Jeneldl1 Puzzo shall promptly
submit proof that outstanding medical bills have been paid (through
presentation of receipts or copies of receipts to the court) and
that the proceeds ~eceived for their daughter have been placed in
a federally insur,~d account iD ,,a bank or savings association
organized und~r ~h& laws. or,.ene commonwealth of Pennsylvania, for
th~ ~Q~pose'~ maintaining the funds in said account until Debra
Puzzo attains her 18th birthday on August 5, 2004 (said proof to be
presented through original or copy of bank documentation). Said
account to be marked to indicate that no withdrawal is permitted
without prior Order of Court before August 5, 2004.
4. Daniel A. Puzzo and Jenelda Puzzo shall be permitted, only
after first obtaining court approval, to invade first the income
and then the principal of the settlement proceeds for the
reasonable needs of Debra Puzzo arising from the physical and
emotional injuries she sustained.
5. The court retains the right to require accounting(s) by
Daniel A, Puzzo and Jenelda Puzzo at any time until the date of
Debra Puzzo's 18th birthdny on August 5, 2004.
BY THE COURT:
!F:JJE COPy FROM RECORD
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Exhibit C
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Receipt
Pennsylvania National Bank's
12-Month Variable Rate CD
Debra Puzzo
Name: nDft-f.Co 1 A !Inri
Date of Opening: nR_lli-:-Q4
Amount of CD: $14.094.87
Date of Maturity: 08-16-95
~ccount:0888-35898
Remember: you can add to your CD at any time without changing the maturity date. One
withdrawal per quarter is permitted. You'll receive a statement at the end of each calendar
quarter,
'"",,l,.tA PII'7,n
~ddress:
336 Locust Point Road
MechanicsburR, PA 17055
Thanks for investing with us,
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TODAY WE CREDITED YOUR ACCOUNT
AS DESCRIBED BELOW:
CHECKING' ACCOUNT ~ CREDIT
DATE . 16 1
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"tabliah Variabla laCa Cartificata of DaDOait
for Debra rauo. Withdrawalll for the account
Debra Pus.o
Dauiel A. Pus.o aud Jnalda Pus.o
336 Locuat Point load
Ifachan1caburl PA 17055
AUG 16 1994
CIIIP"
AMOUNT
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exhibit 0
CONSENT TO PETITION FOR RELEASE OF FUNDS
I, Debra Puzzo, consent to the use of a Petition for Court Approval to Release
Funds for the purpose of obtaining funds from Pennsylvania National Bank Account Number
888-35898 to finance my educational trip to Germany so that I may pursue opportunities In
linguistic studies,
72(;f~!~
DATE: ~ t.., 2003
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exhibit E
Purpose for Request of Funds for Gennany Trip
We, Daniel and Ienelda Puzzo, request access to our daughter, Debra's
account to finance a trip to Gennany this swruner, She will be going with
her Gennan class. The purpose of the trip is to expose her to a different
country and their customs and culture. She will be able to develop her
conversational skills as well as share and compare ideas and views with the
people ofGennany,
Debra's teacher believes she has exceptional linguistic ability and should
pursue all opportunities to learn as much and as many languages as possible
in her youth,
Debra has had a desire to explore new horizons and seek adventure all her
life. We see this as an essential part of her personal education to help her
acheive her goals and dreams.
Itemized Expenses for Gennany Trip
June 15th - June 26, 2003
Chartered Trip
AirFare
One meal per day + tip/snacks
Tips for guides and drivers
Musems and Entertainment
Pre-trip expense
(i,e. shoes, clothes and luggage)
Fun money and souvenirs
Mise
$1198.40
798.00
150,00
60,00
200.00
250.00
250.00
93.60
Sub Total
$3000,00
Plus Attorney fees
(estimated)
$ 400
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DEBRA PUZZO, a minor, by DANIEL A. : IN THE COURT OF COMMON PLEAS OF
PUZZO and JENELDA PUZZO, her : CUMBERLAND COUNTY, PENNSYLVANIA
parents and natural guardians, and
DANIEL A, PUZZO and JENELDA
PUZZO, In their own right,
PLAINTIFFS
V.
MICHELLE ASKINS,
DEFENDANT
,
: 94-1882 CIVIL TERM
ORDER OF COURT
AND NOW, this '1 \~r day of October, IT IS ORDERED that the
balance In the Account No, 888-35898 shall be released and made payable to Debra L.
Puzzo and directly deposited In Account No, 9800717469, Routing No, 071900456,
Amcore Bank, Woodstock, Illinois.
Barbara A, Zimmerman, Esquire
For Plaintiffs
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By th~ourt,
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OCT I 5 2004 f
DEBRA PUZZO, a minor, by DANIEL A,
PUZZO and JENELDA PUZZO, her parents
and natural guardians, and DANIEL A,
PUZZO and JENELDA PUZZO, In their own
right,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION. LAW
Plaintiff
No, 94-1882 - Civil Term
v,
MICHELLE ASKINS,
Defendant
PETITION FOR COURT APPROVAL TO RELEASE FUNDS
WHEREAS, Petitioner is DEBRA PUZZO, residing at 180 Ash Avenue, Woodstock,
Illinois, 60098.
WHEREAS, Debra Puzzo has reached her majority as of August 5, 2004, (A copy of
Petitioner's driver's license is attached hereto as "Exhibit A.")
WHEREAS, Debra Puzzo is the beneficiary of funds for an auto accident suffered May
6, 1993, when Debra Puzzo was struck by an automobile driven by the Defendant. (A copy of
the settlement agreement with Ohio Casualty Company is attached hereto as "Exhibit B.")
WHEREAS, by order dated July 26, 1995, the Honorable Harold E, Sheeley approved a
settlement with the Defendant's automobile insurance carrier, Ohic Casually company to settle
the underinsurance claim for a lump sum of $5,000, and four annuity payments of $5,146.34
commencing August 5, 2004, and ending August 5, 2007, the disbursement of which is to begin
at the age of Debra Puzzo's majority. (A copy of that Order is attached hereto as "Exhibit C.")
WHEREAS, the lump sum of $4,800.00, or $5,000 less attorney's fees of $200, was
deposited into a restricted bank account with Pennsylvania National Bank under account
number 888-35898, which funds are to be made available to Debra Puzzo upon reaching the
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age of majority, otherwise by Order of this Court, (A copy of the deposit slip is attached hereto
as "Exhibit D.")
WHEREAS, an Order dated May 14, 2003, authorized the release of $2,500 for the cost
of an educational trip. (A copy is attached hereto as "Exhibit E") Therefore, the Petitioner
requests the release the balance of funds and the closing of the bank account.
WHEREAS, Debra Puzzo is authorized to execute any documents necessary pertaining
to this matter,
WHEREFORE, Petitioner respectfully requests that this Court release the balance in the
Account no. 888-35898 and be to made payable to Debra L. Puzzo and directly deposited in
Account No. 9800717469, Routing No. 071900456, Amcore Bank, Woodstock, Illinois,
Respectfully Submitted,
BARBARA A, ZIMMERMAN" P,C,
By:
(
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DATED:
q- 8'O~
n, Esquire
Supreme Court I 0, 50572
355 N. 2111 Street, Suite 207
Camp Hili, PA 17011-3707
Attorneys for Plaintiff
(717) 731-1484
VERIFICATION
Debra Puzzo has read the foregoing Petition for Court Approval to Release
Funds and hereby affirms that it is true and correct to the best of her personal information.
knowledge and belief. This Verification and statement is made subject to the penalties of 18 Pa,
C.S. 4904 relating to unsworn falsification to authorities. She verifies that all the statements
made in the foregoing are true and correct and that false statements may subject her to the
penalties of 18 Pa, C,C, 94904,
y~~~
Debra PuzzO'
DATE: ~ok.c..bor ~I ?/iAq
,
CONSENT TO PETITION FOR RELEASE OF FUNDS
I. Debra Puzzo. consent to the use of a Petition for Court Approval to Release
Funds for the purpose of obtaining the balance of the funds from Pennsylvania National Bank
Account Number 888.35898,
CD~~ V~
Debra PuzzeY
DATE:
,
EXHIBIT A
,
1iKenc" (W., 2!58ll24b Jpeg)
Jesse Whtle . Seaelllry 01 Slale
'. ',''T'' :o...J t. _APIR'
,''-0: :~,;;('::: 12-31.02
DEBRA L PUZZO
180ASHAVE
WOOOSTOCl< IL-SKIlB
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DANIEL A PUZZO
160 ASH AVE
WOODSTOCK ILeoc:IlB
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EXHIBIT B
.
SETTLEMENT AGREEMENT AND RELEASE
This Settlement Agreement and Release ("Settlement Agreement")
is entered into by and among the following parties: Deborah Puzzo, a
minor, by and through Daniel Puzzo and The Ohio
Casualty Insurance Company (hereinafter collectively referred to as
"the parties"). "Claimant" shall collectively mean Deborah Puzzo, a
minor, by and through Jenelda Puzzo and the heirs,
executors, administrators, personal representatives, successors and
assigns of same; and "Insurance Company" shall collectively mean The
Ohio Casualty Insurance Company and the successors and assigns of
same.
I. RECITALS
A. On or about May 6, 1993, Claimant sustained personal and
physical injuries as a result of the alleged tortious conduct of an
underinsured tortfeasor, all of which is hereinafter referred to as
the "Occurrence". In connection with the Occurrence, Claimant has
asserted a claim against Insurance Company in accordance with the
underinsured motorist coverage provision of Claimant's policy with
Insurance Company.
B. The parties desire to enter into this Settlement Agreement
to provide, among other things, for certain payment(s) in full
settlement and discharge of all claims and actions of Claimant
against Insurance Company for damages arising out of or due to the
Occurrence, on the terms and conditions set forth herein.
NOW THEREFORE, it is hereby agreed as follows:
II. RELEASE
In consideration of the lump sum payment set forth herein and
the promise to make the periodic payment(s) set forth herein,
Claimant hereby releases and forever discharges Insurance Company
from any and all past, present or future underinsured claims for
damages for personal and physical injuries which Claimant has or
claims to have against Insurance Company, for or in any manner
arising out of the Occurrence. This release and discharge shall be
a fully binding and complete settlement among all parties to this
Settlement Agreement. This release is entered into in settlement of
an underinsured motorist claim arising out of the Occurrence.
.
III. UNKNOWN INJURIES
Claimant fully understands that Claimant may have suffered
personal and physical injuries that are unknown to Claimant at
present and that unknown complications of present known injuries may
arise, develop or be discovered in the future, including, but not
limited to, subsequent death or disability. Claimant acknowledges
that the consideration received under this Settlement Agreement is
intended to and does release and discharge Insured and Insurance
Company from any claims for, or consequences arising from, such
injuries and the Occurrence/ and Claimant hereby waives any rights
to assert in the future any claims not now known or suspected even
though, if such claims were known, such knowledge would materially
affect the terms of this Settlement Agreement.
IV. PAYMENT(S) TO CLAIMANT
A. Lump Sum. Claimant has received Five Thousand Dollars and
No Cents ($5,000.00), receipt of which is hereby acknowledged.
B. Periodic Payments. Insurance Company hereby agrees to make
the following annual payments to Deborah Puzzo. The sum of Five
Thousand One Hundred Forty-Six Dollars and Thirty-Four Cents
($5,146.34) per year, shall be payable to Deborah Puzzo commencing
August 5, 2004, and shall continue through August 5, 2007 (four (4)
annual payments). If Deborah Puzzo dies before August 5,2007, the
payments set forth in this Paragraph IV.B shall be made as due to
, upon proof of death being furnished to
Insurance Company, or to such other beneficiary or beneficiaries as
Deborah Puzzo shall designate, in writing, after reaching the age of
majority and prior to her death, to Insurance Company. No such
beneficiary designation or revocation thereof shall be effective
unless it is in writing and delivered to Insurance Company.
C. Nature of Payment(s). All sums paid to Claimant pursuant to
this Settlement Agreement constitute damages on account of personal
injuries or sickness, in a case involving physical injury or
physical sickness arising from the Occurrdnce are intended to fall
within the meaning of Sections 104(a) (2) of the Internal Revenue
Code of 1986, as amended.
V. FINANCI~G OF PERIODIC PAYMENT OBLIGATION
A. Insurance Company as Obliqor. Insurance Company shall, at
all times, remain directly responsible for the continuing obligation
of making all periodic payment(s) set forth in Paragraph IV.B.
Insurance Company's duty to make such periodic payment(s) shall at
all times be, and is, an unfunded and unsecured obligation to pay
money to Claimant in the future and Claimant can rely solely on the
general credit of Insurance Company for collection of the payment(s)
2
(:...--.....,
set forth in Paragraph IV.B. Insured has no duty to make such peri-
odic payment(s).
B. Third Party Payment. It is understood and agreed by the
parties that, as a means of providing a source of funds for Insur-
ance Company to satisfy its obligation to make periodic payment(sl
to Claimant pursuant to this Settlement Agreement, Insurance Company
will purchase, for its own investment purposes, an Annuity Contract
from The Ohio Life Insurance Company (the "Annuity Contract")
immediately upon execution of this Settlement Agreement. Insurance
Company shall be the owner of the Annuity Contract and shall have
and retain all rights of ownership in the Annuity Contract. For its
own convenience, Insurance Company shall direct The Ohio Life
Insurance Company to make the periodic payment(sl directly to the
respective payees designated in Paragraph IV.B. Such payment(s)
will be applied against the obligation of Insurance Company to such
payees, as set forth in this Settlement Agreement.
C. Status of Claimant. Claimant acknowledges that Claimant has
no right to receive the present value of the payment(s) due Claimant
pursuant to Paragraph IV.B, or to control the investment of, or
accelerate, defer, increase or decrease the amount of any payment(s)
required to be made to Claimant. Claimant shall only be entitled to
receive the payment(s) specified in Paragraph IV.B when due.
VI. NONASSIGNMENT BY CLAIMANT
The periodic payment(s) to be received by Claimant pursuant to
this Settlement Agreement are not subject in any manner to
anticipation, alienation, sale, transfer, assignment, pledge or
encumbrance by Claimant.
VII. ADEQUATE CONSIDERATION - DENIAL OF LIABILITY
Claimant agrees and acknowledges that Claimant accepts
payment (5) of the sums that Claimant is to receive pursuant to this
Settlement Agreement as a full, complete, final and binding
compromise of matters involving disputed issues regardless of
whether too much or too little may have been paidi that payment(s)
of the sums to Claimant shall not be considered admissions by any
party hereto of any liability or wrongdoingi and that no past or
present wrongdoing on the part of any party shall be implied by any
payment (5) .
VIII. ENTIRE AGREEMENT
This
Claimant
herein.
Settlement Agreement contains the
and Insurance Company with regard
There are no other understandings
entire agreement between
to the matters set forth
or agreements, verbal or
3
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/
otherwise, in relation thereto, between the parties except as hereln
expressly set forth.
IX. READING OF AGREEMENT
In entering into this Settlement Agreement, Claiman~ represents
that Claimant has completely read all terms hereof and that such
terms are fully understood and voluntarily accepted by Claimant and
that Claimant has been adequately represented, or has had
opportunity to seek representation, by counsel of Claimant's choice.
X. TRUST OBLIGATION
Claimant agrees to take, through any representative designated
by Insurance Company, such action as may be necessary or appropriate
to recover damages suffered by the Claimant in the Occurrence from
any person or organization who may be legally liable therefore.
Claimant agrees to hold any monies recovered by Claimant from such
person or organization in trust and paid first to Insurance Company
to the extent of the payment(s) set forth in Exhibit A plus the
amount incurred by Insurance Company for expenses, costs and
attorney fees in connection with the recovery of such monies;
provided, however, any monies remaining after such payment to
Insurance Company shall be retained by the Claimant.
XI. SUBROGATION
Claimant hereby assigns and transfers to Insurance Company each
and all claims and demands that Claimant has against any other per-
son, firm, property or corporation, arising from or connected with
the Occurrence; and Insurance Company is hereby subrogated in
Claimant's place and to Claimant's claims and demands and Insurance
Company is hereby authorized and empowered to sue in Claimant's name
or otherwise.
XII. FUTURE COOPERATION
Claimant covenants that Claimant has not released or discharged
any claims or demands arising out of the Occurrence and that
Claimant will assist and cooperate with the representative
designated by Insurance Company to recover damages suffered by
Claimant. Claimant further agrees to execute any and all
supplementary documents and to take all additional actions that may
be necessary or appropriate to give full force and effect to the
terms and intent of this Settlement Agreement which are not
inconsistent with its terms and which may be necessary to recover
such damages.
4
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, .
XIII.
INDEMNIFICATION
In further consideration of the payment(sl and the promise to
make future periodic payment(sl set forth herein, Claimant agrees to
indemnify and hold harmless Insurance Company and all parties .
released against any and all medical or other liens, or claims that
are, have been in the past, or may be in the future asserted against
anyone as result of the aforesaid Occurrence.
XIV. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT
This Settlement Agreement has been negotiated by the parties.
Claimant warrants, represents and agrees that Claimant is not
relying on the advice of Insurance Company, its counsel, or anyone
associated with Insurance Company as to the legal and income tax or
other consequences of any kind arising out of this Settlement
Agreement. Accordingly, Claimant hereby releases and holds harmless
Insurance Company and any and all of its counselor consultants from
any claim, cause of action or other rights of any kind which
Claimant may assert because the legal, income tax or other .
consequences of this Settlement Agreement are other than those
anticipated by Claimant.
XV. COURT APPROVAL
Claimant represents that Claimant has received any and all
necessary court approvals to enter into this Settlement Agreement.
XVI. CONTROLLING LAW
This Settlement Agreement shall be construed and interpreted in
accordance with the laws of the State of' Pennsylv nia.
Dated: ~
through Daniel PUZZC
~fl~
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De
Dated:
De rah and through
Jenelda Puzzo
The Ohio Casualty Insurance Company
By:
Title:
5
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,
.
.
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.' .
RELEASE OF CLAIMS
For and in consideration of the payment to us of the sum
of Fifteen Thousand Dollars ($15,000.00), we, Daniel Puzzo and
Jenelda Puzzo, individually and as parents and natural guardians of
Debra Puzzo, a minor ("Releasers"), do hereby release and forever
discharge Ohio Casualty Insurance company, its parent and
subsidiary companies, agents, officers, employees and
representatives, of and from any and all actions, causes of action,
claims, demands, damages, costs, loss of services, expenses,
compensation, consequential damage, uninsured motorist claims,
under insured motorist claims 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 6th day
of May, 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
corporations 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 Ohio Casualty 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.
It is further agreed that I will indemnify and hold
harmless Ohio Casualty Insurance Company, its parent and subsidiary
company, officers, agents, employees, insurers, assigns, and
representatives from anyand all liability arising from liens and/or
subrogation claims including any compensation or medical payments
due or claimed to be due under the law, state or federal regUlation
. . I
~
or contract.
We expressly acknowledge that all obliqations to
satisfy such liens are that of releasor not releasee.
We certify that we are over eighteen (18) years of age,
that we are the parents and natural guardians of Debra Puzzo, a
minor, and we further state that we have carefully read the
foregoinq Release and know the contents thereof and we signed the
same as our own free acts and intending to be leqally bound
thereby.
seals this
IN WITNESS
of'?..
19 day
WHEREOF, we have hereunto set our hands and
of -1I"-$"o:-J-
, 1995.
WITNESSETH:
tJ
~~ (J} ~~(SE.a.r.)
J elda Puzzo, paren d natural
guardian of Debra Puzzo
Sworn to and subscribed
before me this 1'1'1....
day of A'1',sT-
19905.
'..k,~_J II, R~
Notary public
My commission expires: Atj. I~ /9'}(,
I'IlJI'AftIN. Bl
?BIf~ K. P~GIJl, t..~rary ~b1i:
lllItIlit1it.:;tclij. Cuml~;:1&nd caa~
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EXHIBIT C
JUl 2 ~ 1ge
DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and 3ENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and 3ENELDA
PUZZO, in their own right,
Plaintiffs
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNT~, PENNS~LVANIA
.
.
.
.
MICHEI,LE ASKINS,
Defendant
: CIVIL ACTION - LAW
NO. 94-1882 CIVIL TERM
IN RE: MINOR'S SETTLEMENT
BEFORE SHEELY. P.3,
MEMORANDUM OPINION AND ORDER OF COURT
A hearing was held today on a petition of the
Plaintiffs to approve a settlement with Ohio Casualty Company,
their underinsurance carrier. I had previously approved a
settlement with the Defendant's insurance company, and at the
hearing today I heard the testimony of Mrs. Puzzo who indicated
that Debra has not had any problems since we had our original
hearing in May of 1994 as a result of the injuries in this case.
"They have now reached an agreement with Ohio Casualty
Company to settle the underinsurance claim, and the agreement is
that a lump sum payment of $5,000.00 will be payable to the
parents, and from that sum of $5,000.00 I will authorize $200.00
of that to be paid to counsel for the Plaintiffs for his
appearance in court today and for preparation of the petition.
The balance of $4,800,00 shall be deposited in an
existing, restricted account that was opened after the hearing
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in May of 1994, and this money shall be subject to the same
terms and conditions as previously set forth.
In addition Ohio Casualty will make four payments of
$5,146.34 commencing August 5th, 2004, and ending August 5th,
2007. Mrs. Puzzo indicates that this has been discussed and is
agreeable to she and her husband, and, therefore, I wIll sign
the order authorizing the settlement of this action with their
underinsurance carrier for the terms above set forth.
It was brought to my attention also that the above
four payments shall be paid by the Ohio Life Insurance Company.
By the Court,
J:;:J ~~
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Zeigler, Esquire
Plaintiffs
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DEBRA PUZZO, a minor, by
DANIEL A. PUZZO and JENELDA
PUZZO, her parents and
natural guardians, and
DANIEL A. PUZZO and JENELDA
PUZZO, in their own right,
Plaintiffs
NAY 1 9 1S94
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
MICHELLE ASKINS, CIVIL ACTION - LAW
Defendant NO. 94-1882 CIVIL TERM
IN RE: MINOR'S SETTLEMENT
BEFORE SHEELY. P.J,
MEMORANDUM OPINION AND ORDER OF COURT
A hearing was held today on the petition to approve
the compromise settlement in the above-captioned case. The
Court is satisfied from hearing the testimony of the minor's
mother that apparently she has recovered from the injuries
sustained in this accident except the mother did indicate that
there may have to be something done with some bottom teeth, and
that will have to be resolved in the future.
The petition alleged that the maximum limit of
coverage of the Defendant in this case was $25,000.00, and the
Defendant's insurance company has agreed to pay that sum in
settlement of the above claim,
At the hearing today we heard that the Plaintiffs' own
insurance carrier, Ohio Casualty, apparently is proposing to pay
the Plaintiff an additional $15,000.00 from the underinsurance
coverage on their policy. That has not been made definite at
this time, but in the future Ohio Casualty will be pay that sum.
The Court will sign a release accordingly, and the
Court would direct that should that be the case, that the
Puzzo's, as natural guardians of Debra, are authorized to
receive that money provided that it is also deposited in an
-
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Public Welfare and Dunicl A, Puzzo and Jenelda Puzzo are hereby
appointed custodians of the remaining proceeds from the T\1enty-five
Thousand ($25,000.00) Dollar settlement.
3. Daniel A. Puzzo and Jenelda Puzzo shull promptly
submit proof that outstanding medical bills have been paid (through
presentation of receipts or copies of receipts to the court) and
that the proceeds received for their daughter have been placed in
a federally insured accoun~ in .a bank or savings association
organized under ~he Laws. ot,,~ Commonwealth of Pennsylvania, for
th~ ~n~pose.~ maintaining the funds in said account until Debra
Puzzo attains her 18th birthday on August 5, 2004 (said proof to be
presented through original or copy of bank documentation). Said
account to be marked to indicate that no withdrawal is permitted
without prior Order of Court before August 5, 2004.
4. Daniel A. Puzzo and Jenelda Puzzo shall be permitted, only
after first obtaining court approval, to invade first the income
and then the principal of the settlement proceeds for the
reasonable needs of Debra Puzzo arising from the physical and
emotional injuries she sustained.
5. The court retains the right to require accounting(s) by
Daniel A, Puzzo and Jenelda Puzzo at any time until the date of
Debra Puzzo's 18th birthdny on August 5, 2004.
BY THE COURT:
T;:>,,- C-'.Y
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EXHIBIT 0
Receipt
Pennsylvania National Bank's
12-Month Variable Rate CD
Debra Puzzo
Name: n~".,.a 1 A ~n,l
Date of Opening: 08-1 n-q4
Amount of CD: $14,094.87
Date of Maturity: 08-16-95
Account: 0888-35898
Remember: you can add to your CD at any time without changing the maturity date. One
withdrawal per quarter is permitted. Youll receive a statement at the end of each calendar
quarter.
fa.na.l,1.A PII'"n
Address:
336 Locust Point Road
Mechanicsbur2. PA 17055
,
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Thanks for investing with us,
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,Pennsy' lvania N3tiOO3faan~~ TODAY WE CREDITED YOUR ACCOUNT CHECKING ACC60UNT :. CREDIT .
. AS DESCRIBED BELOW:
OATE
latabllah 'ad..hla laea Cart:1ticaea of Deuoaie
Jor Debra ....80. lliehdraw1Jl tor tha accoUlle
.ue be aaebowad by a Coure Ordar.
r
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888-35898
AMOUNT
DIIbra l'uUo
DaI:I1e1 A. 'u..o and JAII8lda Puaao
336 Locuae hine load
Ha~haft1e.barl'ol 17055
AUG 16 1994
ClllPHI
1$
14. 094.
i 871
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ACCOUNT NUMBER
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EXHIBIT E
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MAY 1 2 2003 '&
DEBRA PUZZO, a minor, by DANIEL A.
PUZZO and JENELDA PUZZO, her parents
and natural guardians, and DANIEL A.
PUZZO and JENELDA PUZZO, In their own
right,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION. LAW
Petitioners
No. 94.1882 . Civil Term
v.
MICHELLE ASKINS,
Respondent
ORDER
AND NOW. this J!L day of
Puzzo and J~n~ld'ii Puzzo as ~tarents Rn~'p
-toto.\ G\.~oUJ'\ or,:J.:J
c:.,Ann' I ~
of funds in the .",,!_..t wf - - u.. .
i~ Cl.u..~orl 'Z.ed..
anutL. "-I'" H..""...r
. 2003. upon the petition of Daniel
ral,guardlan!i of Debra Puzzo. a minor, a release
Q TOWo.t"c.-o'h e-
. which represents costs for the educational trip
The balance of the funds not disbursed by this Order are to remain in the structured
settlement payable to Debra Puzzo upon reaching her majority, The balance of the monies
shall be remain in separate insured. interest bearing accounts.
The af~resaid amount is approved for payment directly to Daniel A. Puzzo and Jenelda
Puzzo. parents and natural guardians of Debra Puzzo. on behalf of Debra Puzzo,
Daniel Puzzo and Jenelda Puzzo. as parents and natural guardians of Debra Puzzo, a
minor, are authorized to execute all documents necessary to effect the resolution of this matter,
~~
J.
DEBRA PUZZO, a minor, by DANIEL A.
PUZZO and JENELDA PUZZO, her parents
and natural guardians, and DANIEL A.
PUZZO and JENELDA PUZZO, In their own
right,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION. LAW
Plaintiff
No. 94.1882 0 Civil Term
v.
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, .
Defendant
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MICHELLE ASKINS,
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PETITION FOR COURT APPROVAL TO RELEASE FUNDS
WHEREAS, Petitioners are DEBRA PUZZO. a minor, by DANIEL A. PUZZO and
JENELDA PUZZO, her parents and natural guardians, and DANIEL A. PUZZO and JENELDA
PUZZO, In their own right, residing at180 Ash Avenue, Woodstock, illinois, 60098.
WHEREAS, Debra Puzzo Is a minor residing at 180 Ash Avenue, Woodstock, Illinois,
60098, under the care of her parents and natural guardians, Daniel A. Puzzo and Jenelda
Puzzo.
WHEREAS, Debra Puzzo, a minor, Is the beneficiary of funds for an auto accident
suffered May 6,1993, when Debra Puzzo was struck by an automobile driven by the Defendant.
(A copy of the settlement agreement with Ohio Casualty Company Is attached hereto as "Exhibit
A,")
WHEREAS, by order dated July 26, 1995. the Honorable Harold E, Sheeley approved a
settlement with the Defendant's automobile insurance carrier, Ohio Casualty company to settle
the underinsurance claim for a lump sum of $5,000, and four annuity payments of $5.146.34
commencing August 5. 2004, and ending August 5. 2007, the disbursement of which is to begin
at the age of Debra Puzzo's majority, (A copy of that Order Is attached hereto as "Exhibit B,")
3, The proposed trip to Germany is an appropriate use of the funds for the minor
child.
4. The minor child has appropriately requested these funds,
WHEREFORE, Petitioner respectfully requests that this Court release the funds in the
amount of $3400 (est.) ;which represents costs for the educational trip and attomeys'
fees,
Respectfully Submittea,
BARBARA A. ZIMMERMAN., P.C.
By:
'J
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Barbara A, Zimme' an, Esquire
Supreme Court 10.. 0, 50572
355 N. 21"1 Streei. Suite 201
Camp Hill, PA 17011.3707
Attomeys for Plaintiff
(717) 731-1484
"
DATED: May 7, 2003
WHEREAS, the lump sum of $4,800,00, or $5.000 less attorney's fees of $200, was
deposited into a restricted bank account with Pennsylvania National Bank under account
number 888.35898, which funds are to be made available to Debra Puzzo upon reaching the
age of majority, otherwise by Order of this Court. (A copy of the deposit slip is attached hereto
as "Exhibit C,")
WHEREAS, Daniel A, Puzzo and Jenelda Puzzo as parents and natural guardians of
Debra Puzzo, a minor, are authorized to execute any documents necessary pertaining to this
matter,
WHEREAS, Debra Puzzo, a minor child, has the opportunity to travel to Germany for an
educational opportunity sponsored through her high school,
WHEREAS, Debra Puzzo. a minor child has requested release of the funds from the
restricted bank account to finance the purchase of this trip; otherwise, Debra Puzzo would not
be able to attend, (A copy of Debra Puzzo's request and consent of the release of funds is
attached hereto as "Exhibit D,")
NOW THEREFORE:
1. . The Petitioners are in favor of granting child's request for release of funds in the
amount of $3,000 plus attorney's fees to finance the trip to Germany, plus
attorney's fees to obtain these funds, the costs of which are itemized in "Exhibit
e." attached hereto,
2, The proposed trip to Germany is an educational trip and in the best interests of
Debra Puzzo. a minor,
:-....::-..-...
"
VERIFICATION
WE, Daniel Puzzo and Jenelda Puzzo, parents and natural guardians of Debra
Puzzo, a minor, have read the foregoing Petition for Court Approval to Release Funds and
hereby affirm that It is true and correct to the best of our personal Information, knowledge and
bellef. This Verification and statement is made subject to the penallies of 18 Pa. C.S. 4904
relating to unswom falsification 'to authorities, We verify that all the statements made in the
foregoing are true and correct and that false statements may subject us to the penallies of 18
Pa, C,C, ~ 4904,
;"
DATE: YK., h
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Jen a Puzzo
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. .
CONSENT TO PETITION FOR RELEASE OF FUNDS
I, Debra Puzzo, consent to the use of a Petillon for Court Approval to Release
Funds for the purpose of obtaining funds from Pennsylvania National Bank Account Number
888.35898 to finance my educationaltrfp to Germany 50 that I may pursue opportunities In
linguistic studies.
~*zz!~
DATE: ~ 1.., 2003
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