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1'lalnlll1i. clleculorl oflho clla,e ofCryllall,. nankert, de(ealed, aro authorlud 10
dllconllnu'lhe aforeaald .cllonl and 10 ellocul. and deliver a llood and lumclenl relea.. oflho
cl.lml oflho ellato under bolh Ihe wronllful dealh ICllon and lurvlvlllcllon allllnll Samu,l
CarannalO and COllmo MallchCi:chlao and Allltalo Inluranco Company and 1!rle Inluranco Oroup,
reIPCi:livrly, Ipcclllcllly reservhllllho rlllht 10 brlllll luh allllnll any olher orlllnlullon, penon or
IllltfeallUr who may have Iiabilily arlllnll oul oflhe accident, InJurlcl and dealh ofCry"al L,
llankel1, decealwo Includlnll. bul nullimh,d 10 Ihe rl,lhllO mako I claim Ibr undorlnlured
molorlll benellll und,r deced,nl'l own aulomobile Inluranco policy or any other polley und.r
which Iho 'I.at. may bll ablolo claim,
. ,.
'1',. .,..:, ...~.,.1t.~ ""'..... ,,~ Al... ,,,'~.,..... ,.J.'l 1'_ '",.,....
t-. ,..".,.
UllllCutlon o/a relea.. and paymenl oflho.um of Thlrty Thouland and noflOO
(SJO,ooo.oo) DoUan II albrenld IhaU conllhute evidence of com pic It ntllliclion otcl.lntI and
demandl ofwhallOever kind or nature oflhe ealalo of Cry III I L, nlnkert. decelaod, under Ih.
lurvivalacllon and a110 of III perlOn. enlhled 10 recover wron,ful dealh d1malltll. . r'lUlt ot
tho albreaald 14'Cldenland dealh IlfCry.tal L. Uankert. d,"a.od, 11I,lnll Samuel Caranllll, and
CUllmo Mallchel:chll. and AUllalolnluraneo Company and IIrl,lnluranco Oroup 10 Ih, Illtenl
lei forth abov., howevlr, ..Id paym.nt .hall 001 conllltul, evidence ot nllllictlon of any clllm
Illlln'l any olh... p.raon, orpnlullon or IOl1f,..or. II afllulnld,
By 1M COlII1,
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4 l),fendanlSamuel CIl'ln"a'Oo all adullllldlvldual who at laid limo rellded 11214
Hili Kin, Slr"I, Shll'von.llIlrj, Cumborllnd Cuullly,l'ollnlylvallla 17257, bul wholO prolOnt
Iddr... Ind whorOllbllull il unktk,wn. wltlho driver orlho 11I0101' vehltlo whldt ..ruck Iho
vehle'.I" which d(l(;ede"l W'I rldh,>> II . "..aenll,r. whe" defend.nllailcd 10 Itop ror a Ilop .111"
I:\mlrolllnll hl,llno of"'\',I.llho IIIU!tlOcllon ofl'a, I\oulo 174 (Old York Road) and I'a, Roulo
l4 (11011)' I'.h)
5 AI uld Ihno. lI,lendlnl Carannalo malnlained an aUlomobil,lnlutll\CO policy
luutd by AII.III.llIlYr.",. CUlllpa"y (I'uliey Nu 07776441'), wllh lIabUlIy Iimill for bodily
Injury In ,''' amoonl or $1 ',000 ()(l
6 lltltndant Cotimu Madc,*,h1a. an adult Individual rolldinllal214 Ball Kin>>
!illtot. Shlpptn*,tllo Cumbtr'and Coonly.l'tnnl)"vanil 17257, wa'lho owner orlh. v.hlel.
Ilfinll dtlvfll by d.fendant Carannal. lllho tlmaof I'" ~Id.nl.
7. At MId linlt, d.ltndant MIII~h1. fnalnlailltd an aulomobil,lnlUranco polky
.nuflt by I!rif IlINanc' Oroop (I'olk)' Nu X07 "0) 14511). with liabillly Iimlllfur bodily Injury
in I'" amount 0(115.000 00
. AI MId tlmo Cryllal L Dankl!ft w.. a mtmbu of lho lwuMhold or JII11tI J\,
U~tf1 and Judy I) hanhft, y()llt pttlllollffl. who 1tlIi1l1ll1ltd Ihr.. IUI()ffi()bllo lnturlllCl
po'k:ift ItIUfd by !j..I. rann Inturanc'IH1I"''' IOplfll' \'fhklo.. ",h with IlKkablo
~jnturlll(.f poIky litr~11 of II MOO 00
II I'WfltrW.' Iilll.llMd "'" b<<n I/hl"'" IbtlIU~ lIarm'llIUftll(. "-- p<<tonned Nt
~ ,.k (HJ ~ ('arMMl. ~ M,'Ik:~ W fWIl4lh/Jt Nit_ pari)' "-- MY (oIJt(tiWt
wn. M4...., iA "".. 1_".... *~ M4 "...~. vlClllWol. it ~Il(lW"',
10, Oolh AlIllale Inlurane, Company and (!rle InlUraneo Group have ollCred 10 acllle
Ihe claim agllnll Carannal. and Ma,lehecchla. relpccllvely, for $15,000,00 each and plalnlll1i are
..lilned Ihal Iholo olTerland lho propolell lelllemenl aro in Iho belllnlerolll oflhe ollalo, are
loalonablo and jU11 and are willing 10 aeCq1llhOl' olTell if approved by your lIonorablo Court
II, l'lalnlilli have 1101 nllaliud Ihelr negollallonl wllh Slale 11armlllluranco on Iho
underinluranco claim Ind. Iherefor, wilh 10 reacevo Iho underllllUrancll clallll II well II lho oglll
10 claim and/or bring lull agalnll Iny olher orglniz.allon. pellon or 10nffllOr who may have
liability ariling oul ol'lho accidenl, lnjurleland dealll ofCryllal L, Osllken, dccoalOd, 1I0wovcr.
plalnlllli aro wUlinlllo relea.. defendanl Carannalo and defendanl Maliehcech1a. Allllale
lnsurane" Company and llrlelnaurance Group, relpecllvely. upon lho plymenllo litem oflho
S I Moo,OO policy Iimll. nom OIch defendanl.
12, Pllinlll1i, a'lho plrenl. and 1010 heir. of decedenl, arelho only poraoRl enlllled 10
recover damagea Illr de<<lllenl" dealh
I), I'rtlllonen have allreed 10 pay allomoy fee, baNd on 25% of tho lolal amounl
recovered In any OUl.(lf.eouI1 aclllelllenl Ilflhl. mallet.
14, Thelo\ilfuncral bllllbr lho d~enl wa' $7.61500, ofwlllch $5.000,00 wa, paid
Ifllln lho prOllMd. of funeral bill bencnl. Itom IUlomobilolnlUranco cuvtfap,l..vln>> a balanco
duo on the funtral bill of $2.0U 00
U 'l'lw PelWylvlllia lRpa.nlOOlt (It Welllr. ha. advlll<<d lilt total """ of
$1....67.97 for Lbo ptylOOll of mtdicII.~penae. "U'iblillWe 10 mtdicII treatlllMl rend<<cd 10 II"
lk<fdfIII JlIi4lf \0 h<<...1\. for ~hldllht IRl"JltIWAI hvld. al\UbtPjllloo 1Im.1 provWt4 1ft 1M
I'ublie Welllno Codo. a. amended by AeI1980.I05. 621'.8. Secllon 1409 (bX I) el'lXl. and
S\.ocllon 1974 ellell. and Iho Social Securlly Acl, 42 U,S"C, Secllon 1396a (2') and Secllon
IW6k,
16, Accordinllly, pellllonen propolO 10 allocalo IhOlolalaum 0f$300ooo.oo In Iho
aforeDld IOlIlemenl proceed a II followl:
A, $10,185.00 10 Iho wronlllUl dOllh aelloll,lo bo dlllrlbulcd al followl:
I,) 57,500.00 for IUomoy fool reprolOnl1na 25" oflho lolal rowvery;
2.) $1.685,00 10 pay tho balanc. oflh.lUneral bill; and
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:. (/J< ,'i ( ~,j1/ t-'
. IIAKOl,P H. IRWIN. 111 I
AUot"'1 fur plahUll1lIpttllloll,n
>> -'ulll !'IUIUr..'
C.Itim. I'A 17,1)
4717) UJ..WIO
"lip....... fllll" '0 Nfl. 1"'0
It $19.815,00 10 Iho turvlval acllon 10 be hold by petlllonor. aa In 11101 oflh.
"'at., 10 b. dlllrlbuled 10 Ih, "ennlylvanla Deplrtmenl of I'ublle Welfare III ply 1,llnll
Ih. tubro.-lion lion held by ..Id Deptl111lenllbr lho rolmbulMlllM1 of nlOdlcal..pon...
"ald on behalf oflhe ellalo by Iho D.partmen\.
WUIC'U:FOIU:, pelhlonen rOllu..1 your lIooorablo Court n,r loa~olllllltllo ,nd
dllCOnllnu.lh. wron.lUl doalh Ind tul'\'ival action 1bI1halollltum lIrl'hltty l1K1UDnd and
11I1/100 ($300000 00) (>QUart and approvo lhlall(gllon and dl.ulbullonl. IlXluOltod
TItt l\l,ftUllIj ptlllklf1 i. NIfIl upon iflfil(fIIIlloo whith hal botn ,II""'" by my wunMl
In lilt pltpAfalloo or Ihl. mall" lilt I.njlll.... IlfI'" ~llmtllll, ,''' IlIIjU'lI' or my wunHl
IlId ",II my own I M~' "ad I'" ptliliv" and 1II1hf ._tfflllhal ill. b....., upon Inlbrmallon
whkh I ha~'lIl~'" III InY {(llImtl. it II lUll! ifili {(Iff'" III I'" bI.. (It my krwwlq., lnlbnnalkHl
IlId btll.t 'I'lllht .,Ifllllhlt lilt Wlllfl,1 lit I'" ptlttloo I, lhaI (It '{IlI11111, I ha~. ,.lIed upon
~(,"nMl ifll11Ikl", Ihl, ~ffllk.lioo t undtfttand IhIt I'atN .llIffIlf(Il. madt ""tin If. ~IIO
Ih. ptnalllt.llr II Pa C M ^ "...1100 4(11.I40 '.11nt \4J Uf\IwOfn IiIlllkalloo 10 IUlhorlll..,
J,lIu.ry 10, IW'
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IIAROLP So IRWIN. III, ItllQIJIR':
All'ORNEV Ib NO, 2"20
J6 SOU1'II1'IlT "'fRIEl'
CARUSU: I'A 17UIJ
(717) UJ-609U
A'I"ORNltV t'OR DItJlt:NPANl'
JAMES It. IIANKF.lfI' and JllUY D.
IIANKt:ltT, 'ltfulon or Ill, t:STATE
urCltYSTAI.I.. IIANKt:ItT, d'f,."d,
1'lallllllT.
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IIN Tilt: COURT 0... COMMON PLEAS 0...
I CUMUEItLAND COUNTY. PENNSYLVANIA
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I CIVil. ACTION. 1..\ W
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I NO, '1,>,)(/ '(,. CIVIL TERM
I
I IN TIU:SI'ASS
SAMUEL CAltANNA'....: alld
COSIMO MA'nCm:c(~IIIA,
",r,"dll"l.
QB.D&R OF COlJRI
NOW,lhl. -Li:. day ofl'obruaryo 199~0 un pOlllion ufll10 plainlll1i and on mellon of
Harold S. Irwin. Ill. Iltqulro. allornoy fur Iha plainlll1l,leavo I. hfreby >>ranled 10 Ih, plalnlil1i 10
""10 and dlKOnllnu,lh, ealale'a cllim n'r uninlUred mOlorl,l. benonla a,lo Ih, policy of Chid
Illlurley fur Iho SUII1 of fillcen lhou.and ($1 MOO (0) 1>Olla". and "10 the polldoa of JlmOl
1\, Uankel1.nd Judy Il Ulnkel11br Iho lolal.um ofllony.llv. Thouland,lhoao aurn. belnl
aUOtllled a. follow.'
I, U4.0~O 7Q 10 Ih. wronlll\ll dO.lh acllon. 10 be 1I1'lribultd a.lbllow.:
A SU.OOO 00 for allorney I're.; and
U S)\J.O~07lJ 10 J.lIlta It Uaoh" and Jully I) Ulllhl1. aurvlvllll parMI.
and ",I, hell. .Iltw ilI'lhe ckcftM4. and
2, $5.97\1.21111 Ihe survival aCllon 10 bo held by polilioller. alan allel oflho el18100
10 bo dlllrlbul~ 81lbllowl:
A, $3,4) 1.47 10 Ihol'ennlylvanla Oepal1menl of Public Welfaro 10 ullllY tho
lubro1l8110n lien held by IIld OOl'artmonl for Iho reimbursement ofmcdlcal expenlel plld
on behllf of lho ellllo by Iho Departmenl; Ind
l), $2.547,74 to Jlmelll. Dankort and Judy D. Dankert. admlnlllrltor. oflho
ella.. of Cryslall. IIlnkert lbr Iho paymenl of Iho bllll Ind expenlel Iill~ In (!llhiblt "COO
al\8ch~ 10 Iho pelltlon.
1'llinlilJi, execulors llf Ihe ellllo of CI)'IIII L, Dankert,llO<<lICd, Ire aUlhorlzed to
dilconllnuo Iho aforeuld lelhlnl and 10 executo Ind deliver allood Ind sumclenl rei.... oflho
unlnsurtld molorisl c1llml of 1110 ellll' under Ih, Brl, Inauranc, Group policy of Chad D, Hurley
and 1110 Sla.. Vamllnlurl",' pulidol of Jlme' R. IIlnhrt and Judy 0, Olnkel1,
l!xecullon ofa roloalO and paymenl of tho luml of Hfteen Thuuund and noIlOO
('''.00(100) Dollar I and J1l1rty.nvoThouund and 110/100($45.00000) Dollarl.. albr.aald ....11
conslillllO evldo",o IIf complclo ..lilllctlon of clalml and d,mlnds of whlllOOVer kind or nalure
oflho "llle afCryll., t. Ulnkel1.11ecM.edo under lho survivlll':lionllld 1110 urall perlOl1'
fIIlhl", 10 recover WHlnlllUlll'llh dlmlll" II a fllllll of lilt aroro..ld ac:c:ldenl Ind dOllh of
Cry.laI L, Oank"1. docealOll, aplnal Chod II. Hurley. a. Wllllllho unde,lnturance ~v.rIJOI of
('hJd U tlurley and of Jllllta R Oanken Ind Judy U lIankfft
lJy lho rWlt,
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JAl\1r,,1I It UANl\lm'filld illUY o:-Iiii{'iilt: c()irl.'{6fo' CUMMON "LiAS or
lIANI\r..tT, flffu'on orulf t:STA'l't; I C:IJI\tUr.IU.,\NO COUNTY, 1't:NNSYI.vANIA
orCRVS1'AI.I.. UANI\t:ltT, IIm'ltrd, I
1'lal"tIITI I
I CIVil. ACTION. 1.,\ W
I
I NU.
I
I IN TKt;SI'AS!i
\'1.
SAMlllCl. CAltANNAU: a"d
COSIMO MA l'l(:m:CClllA.
O..r""dlllll
(:IVII. n:ltM
NOW COIlt, Jlmollt Uankertlnd Judy I> Uanhrto e~CCUlorl uflh. 011110 ofCryl.a1 L.
Dankert, lI~uaed, by Iheir allorneyo lIarold S. Irwin. 11I0 Caqulro, and prelCllllhll pell.lon lOr
Ipproval or.elllemon. and dj~onllnuall<<l of claim, IfprelOnllnlllllbJlowl:
I, l',.ltlo/lffl I" J.lltollt nlnk,,, Ind Judy D. Uank'l1, IllCCU'orl otlho ...... of
Cryllal L, Uankert. decelwd. lellm of admlnlllrallon havlnll been I..ued 10 ,horn b)' 1110 RIJlI'Of
of Willi ofCurnborl1/ld Counly un AlItllIll III. 1\1\14,
2 "flltlollO" ".Ih. 11II'\'1\'lnll par.n'l.nd 11I1. he!,. of {'f),'al L. O.nk,", docoaaod,
J I><<tdelll IIltd on AlIIIUIlll, 1\194, II lilt 1111I o('w,n.)' (%0) y.arl (dtl. or birth .
S,p..mbfl' 2'0 197)) ..lh. !t1Ul1 uI'lIlJU,iflllllr..VtJ b)' her In IIIlUlumobll,lC(ldtnt on AuiJUaI
7. 1Y'14ln {'umbtllMld ('wIl1Yol'fllllJlylv.M
4 Allho 1111\0 IIl'lho accidolll, d~\l\lonl Will a Pl..on"", in alllullf vehlelt driven by
Chad II. lIuIley, Whll malnlallled a"aulolllobile Inlu,ane, policy l..uOll by Hrlo Inlu,anclI Group
(l'lllley No QIO-600294 1.11), wlueh ~Illey cOOlainetllimUlorbodily Injury liabUlIy In Iho amuunl
01' SIOo,OOO.OO and undo,lnw,od IlKIIlIrlall coverallO lill\lIl \II'S I ',00000, alindiclIotI on Iho
d~lalaUlln pallO oflala Illlllcy, a copy orwhieh II attached heroloalll"hibil"^" and
inco/poralud hOI~n by 'el~lenell
, 1'.tUlon,", Iner a review 01'1110 accldtnlln\'lIllllllllun by Iho l'ennlylvanJa Slalo
"ollee, aro ..Il,nod Ihal Chid n Ilu,'vy wal nolalliullln Ihll accldenl and Ihll tho ,"Ident and
rewlta"t lnJurllll .ud d.all, of d\lCetlenl Cryllall., lIank'l1 w.re Iho dlrocl rowll of Iho nellli>>lIneo
orSall\u,1 CaflMal., and beJievo lhalhllln lht belll"let'll. uflhe OIIalolo ,.10Ut Chad D.
Ilulley from any liability claim In Ihll maUer,
6. Al .ald limo Crya.all.. lIankert w.. a mombor otlhe houMhold or Jamta R.
IIlnke/1 and Judy 0, lllOlIe/1, your pollllon'fI, who /lII1"lalnod Ihreo aulumobUolnlUtanco
IlOlIclollllUod by Slalo falm InlUflOCo on lht.. ..patat. vohlel... ",h wilh al"kabl.
underlnwt.ne. pollcy lim!I' of S I MOO 00, a. lndlctlod on the dedltallon Pili' of IIld pollel..,
Cllpl.. of which Ifl attad10d hefOlo ..Ii"hibh "II" and IIlC~tPO'lletl horein by relfrence.
7. IIpth Illl,'nlUtlfncl O'llOP (UII bohalfofChad II lIull,>,) and Slal,llarm
Inwlllll.'1I (011 """'If of JatlllllR nanhrt and Judy 0 nankerl) hl\'l ol1lred PlY lhe
undOllnwrane4llmll.11I tI~.1 fJIIttrf, Illtll., $1 ',000 00 nom Ih, t1ulley policy and $4',000.00
110m lho 1I.llb'l pI.lllei...nd ptthiollOn II' IIlltn.d Ih4llhe.. ol1tllllld I,", plopoM4
",11"11I'1" II' 1111"- "'tt lntffnlt or th4 nI&I.. .If 1f~J.1Ild Jutt ..,a "" wilJlJw to k<qI
1"'141 II/rtf. if lppIoved by )'Wf IloooflWt ('WIt
I I"tilkl/lffl, .,11It parflllt .nd 11I11. hflll of d~td'nl, 11.1'" lIn1y ptflOn. tnlillfll
hll"{l~'" dIIlllj"1Pt lI~"'I'llI...h
IJ Pttlllullfl.lII~t 1111"" III JII)' IllOfM)' ..... b..... (In :m~ of I'" l()lal amounl
"~II~"fIlln .n)' .1II1-uf<(0UIIlltfllfll"'" IIf Ihlt mill"
10 'I'" t'ftlAl)'lUnil U"llfl1tlfflf IIf Mll4l Wtlrar. U".W) hu ad~Wtd I'" lotal
IUftl (If U4,IClU7 fll/' I'" JIIYflMlnlllf 111fd~ "ptnMI aluibultblt III nlfIIkal UHtI11fftl
"nd'ltd 1111'" lItt:tdfIll ptWt III "" \Iolh. fill' ~ltk.h the Otplllltlfnt Iwkl. llUbrOlJllloo IItn II
P/ll~k1f1lllll'" t\iblitI W.,.... ('PIlf. ..1Il1I8dtd by A4:t IVao.lO~, 611' II ~lon 1409 (b)(1)
"1tlJ and S"'lion luN.. NIl and lilt ~lal ~)' -"1, 0 U . r. ~lktn 1J9Ot (U) and
S"lkm l)96k
II. PPW Ill. .".to UCfPlIIlt Mft ttlm.~.411A ""'...... GIlt.
IUbwjIlkm $lIUn, Ilf ~hk. pIlkkMt "-\'. pal411','" 00 put...... kJ lilt.... ON<< GI
(Ollllrt.lfa\'lnj .lJtlwufU,..lI 47
1 % All'" llmf (It Iwf dIIli. ."'fIIl hili..... 4ttIttlftlt CJlIwf hlWMl..... II
If. h"fIlllIl'" atl~,*, I:dlittil ~C". "tiki __,..... dut and ""lIlJ
I) ^"fI"~, J'fI#kM.,,~ ki Ilk....."" kMlllllft~I6O,OOOOO II ""
albffMltl ...11tmMl pt\l{lItlh II IWltllU
A '~,f,(1~J 7"11./ ~ "'..~..~ w~ ~ N....
II "'.lMJ 00 Ail ~",., .... ,,,,,...,,,,,. %W. &;llltt '~"r, W
H tJlI,U,l(i. 7'1 kI"" 11_." W WI fA lMMff\ WI"'"
""...., ~ ~... .... \It.-. tlMfllol.Ml. tilIl
I), $S,97\l.21111Iho aurvivalactlon 10 bo held by pOllllonora aa.n ...01 oflho
,...10, 10 bt dlalribuled al follows:
I,) $3,431.4710 Iho Pennsylvania Department ofl'ubllc Welliro 10
IIlllry 1110 lubwMallon lien held by laid Dopaf1menl for Iho relmburaom.nl of
modl"l'llponllll plld on bellalfoflho '1lalo by Iho Departmenl; and
2) $2,547,74 '0 James R Rankertalld Judy D, !lank.n. admlnJatralora
of lilt IIslal. 01' ('rylllll. lJankert for 1110 p.ymenl of Ih. billa .nd ,Jlpenlt.II,lod
In llllhlbil "COO all~hed 10 Ih, polilion.
WlIlRtFOHt:. pelitlonera roque.. )'OIIr lIonorabl. CounlOr Involo IOttl. and
dilronllllllO l"'lforlllaid clalml for tho tolalaum offifttf/\ Thoulllld and nollOO (SlS,OOO.OO)
[)ollara and fort)lollv. Thou..nd and 001100 ($0,000 00 ) DolI.r. as aforelald, and approvo lho
.Uoca\ion and dla'rlbutlon aa r"Oqu..tod
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IlAROI,D 8. IItWI ,III /
AUon,,)' for platnll p.,llkJ"'"
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U Seulh Pitt Sin.'
Clttlale, PA 110 J,)
C7I ') Z4.1-6OtC1
8up...."'. Court II) No, 29920
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PIONIER fAMILI AUto POLICT
AMiNDlP DECLAaATIONS 01 . · JrrXCTIYX 0~/21/9'
ATTAca TalS TO TOUR 'OLICY.
RiASON r~R AMINDMENT -AUTO 1 REPLACED, LIINROLDIR ADDID
AA7638 ~RIQORT A GARBITT
l'/le/~~ TO le/le/~' Ql. e0~20.1 R
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MT BOLLY SPRINOS PA 17eC~-1'3I '
AS tUUI'l IU.OW
AOINT - OIllOOBf A GUilTY lieu "UNO lOAD
A~iNT PHONE - (717) Z'J-3t87 CARLISLI 'A 17eI3
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AUTO TIt MAn UN If TU 1Yl'1 P.U'INO oun PPP
1 01 rORp '-lee lrTlrI'~3MtA'51~7 fA 17 6 cat
11tM o. INSURANCE IS 'RO'IDID WIlli A ..I"IUM, OR INCL, IS SHOWH rOR TII
COVIRAOI. CO"RAOIS, LIMITS AND ANNUAL 'IIMIUH, All AI fOLLOWS-
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--- TR! LIMITID TOllr OPTION A"LIIS TO AtL 'II'ATI 'ASIINOJI VEHICLES. ___
LIA~ILITl PROTICTION-
.CDILY INJUR' 'le0M/~IRSON '3'.M/ACO 20'
pROr'~TT DAMAOt .1"M/ACC lRt
FIRST PA~TT J1NfYlIS-
MltllCH IIUNS): 10M 117
lllOOMI LOSS .1M/MOHfK, UM t'UII'lU/'l 3)
ACCIrllNTAL DUTY .~M II
rU~l.IUL IlVNIVIT t2 .~11 ~
UNll1!Uklb ~OTOkIST5 C~'rRAQt-
J)D I~J ~leM/~IRSON .J~M/'CC-STACK&D .
UHDtkIN~UkrD MorOllSTS OO'IIAOI-
bOD INJ .1~M/PrR'ON .3'M/ACC-STACII>> l'
P"f~ICAL VAMAjt CO'tftAGlS-
COMPk!~tNsr't - .~~ DID I1U
COlLl410N - .~0e IlID 311
OPTIONAL COUkAnll- ,
ROAf! ~UYlC! 0
TRA~I' II"N!&J - CJMr tIJ/PAT, '5"/1.011 3 J
nAil';, lUhSU - caL Uf/DU, ""/LOU u ,;
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TOTAL AIIHVAL 'al~IUI1 '01 lAC! AUTO 1'7, 1
'!'')TH AhhUAL POLlCT rUl':lUPl . 1,'76 IJ':
At~I?IQ~.L CIAI~J DOl fO fjl' C'A~O' t 2! III .r'I'IP 1~'OICJ .~ow
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:lI0411^^ct;()K I:JTD nU1COUNT AU1'O IIATr.: QUOTE B'rn II 18COUNT
OlJ(J1'I~ I a 19 71 roRO 1'lmM I 0)7 *QUOTK I 1 19"1 FORD TI!:RRIOl7 *
HCIl -MCD *
1 IH11 OU I <:1,1111 I'ltt::H -UlalOOl CI.llll PREH .
Itlloll 'lO/IIlO/!lO $101.!l0 * f1IPO ~O(' 0(/1)0 tl 08.110 .
.'UI.I. TOJ('r * ru L TORT .
Ht:\l 'IUOOU U6. '14 * HED $10000 U6.74 .
r U!lOO $.91 * ,. $1!l00 $.70 .
Z $'>OUlI 18.!l4 * Z $!1000 ,..D4 -
t:IW ),60 - 1':"8 3.60 *
U !l0/100 tv.l0 * U 1!l/)0 1'.60 *
If '0'100 Ul,lO * If l!i/lO l.liO .
Y U 000 ",10 * Y nooo 1.80 *
Hr.W PRt:NlUN :186.611 . NEIf PRItMlUH :16&.98 *
CIJlCIlt:NT "REHIUM In". * CURRENT PRkMIUH 16&.98 *
OIFrt:IlENCK ~ no." * DlrnMt:NCE .
HOHTItLY I'REMIUM
I'Yl-HODIt'Y RATte QUOTa:
.:U .11 MONTHLY rUJU UM 137.66
,r4-VIEW CURRENT POLICY ACCBPT TO CONTJNUF.
Il\04UAAl!I:1l1< "U'/'IIAI, AUTO RAn QUO'l'K MUTUAL
(Jllun: , 1 1... ..., iii Tl!:IU4IU1" - Qu()'f r. , 2 1V 8"1 rORO R TtRIU 0)" *
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1111'11 -.Cl/IlW /'1(1 U/lO 01 !I - BII'" !,)0(100/!to '380.n *
tIJ 1.1. '/'(lilT - 'U .1, '1'OkT *
Ht.II '\ClOO/l '61,110 * Ma:O '10000 "1.90 *
t tuoa '2.60 - , $noo U.60 *
t- ',000 122,10 * Z t!looo lu.IO *
('UHI' till.!. !)l,Ht * COM I' I'UI,I. !)1,)b *
CUll. ,r,o IIW 'IM\,l(l - COLl, 'allo ulm t1611.10 *
"IOl 12.00 * ItIHI 12.00 *
II aO/l00 'I, '10 * U 1!l/l0 6.!l0 *
W '0'100 ,...90 * W lb/lO 16.10 ..
y fa GOO t4,1I0 * y t!looo 1.00 *
NlcW "litHIUM 'U1.10 * HIW I'MEMtuM $606.110 *
('lIlIlItN',' I'III';M lllM "':14.13 * CURRt:H'r "ntH/UM 1'24.13 *
Illl'rt:I4t:HCk .. '102.U . Dtrt'l:Rt:HCtr. .. 117.62 *
H("nlll,'" VICt:MltIM
I'Y\-V /t.W Af)Pl, QOOTJ:I
'lOl.n
,f)-MODIfY QUOTI
MOHTllLY "REMIUM '101. O.
'f4-VIIW I~L/CY ACCEPT TO CONTINUE
.
IC.~III"" .,..
I. ^danl' llI~lrlc: S 21.64
2, Chlmb.rlburll OIl.ClVN ^I.UC. t'e 105.00
), CarU.I. Ilo.pltal 40,00
4 Chambetlbutll1malllnll Allociale. 170.00
~. 1\ we l!m,rll'ncy l'hYllc1an. 54,00
Cl llelllna MeDelh MI> IIUI
7. 1\ Proderlck Mat1ln MU )0,00
II. Chambenburllllolphal 470,'0
Q Manall.m.nl Sorvleo.,lnc, 170.00
10 ^m.tlean Family I'ubli.hor. 12.9'
II. Ilee or I'hllad.lphla IIa.34
12. earti.l. Memorial Servl'O, loe, l.l~l 00
TOT^I. S 2.141.'74