HomeMy WebLinkAbout95-03048
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State Farm Insurance Companies
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STAliDARD SBTTLEMBNT AGRBMBNT
THIS AGREEMENT entered into this 17th day of October
1991, by and between State Farm Mutuar-AUtomobile Insurance
Company (hereinafter the carrier) and Tina Moj iea (U"r~"..' fVlG.A-""':d)
(hereinafter the uninsured).
1. In forebearance of the filing of a
uninsured agrees to pay to the carrier the
payable as followsl the sum of $50.00
October , 1991, and a like sum of '50.00
each and everY-month thereafter, until the
shall be paid.
suit against him,
sum of $3,372.13
by the end of
by the end and
whole of said sum
the
2. Upon the payment of all monies due according to the terms
of Paragraph 1 above, the carrier shall release and discharge the
uninsured in full for all injuries and for all damages sustained,
to the extent of payment by the carrier.
3. The carrier agrees not to institute any suit to recover
this sum, or any part thereof, as long as the uninsured is not in
default of this Agreement.
4. Waiver of any default shall not affect the carrier's
right upon any later default.
5. I hereby authorize and empower the Prothonotary or Clerk
or any attorney of any court of record in Pennsylvania to appear
for and to enter Judgment against me in the sum of $3 372.13 .
with costs of suit, release of errors, without stay ~ exeoution
and with 10 percent added for collection fees, and I hereby waive
and releaee all relief from any all appraisement, stay or
exemption laws of any State, now enforced, or hereafter to be
passed.
IN WITNESS WHEREOF, uninsured hereby sets his hand and seal
the day and year first above written, with intention of being
legally bound thereby.
WITNESS I
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(UNINSURED)
(OPERATOR'S NUMBER)
(DATE OF BIRTH)
CLAIM NOr 38-6437-144
BY' Cathy Hartman
INSURED, Harold Berrier
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STATE FARM FIRF, & CASUALTY COMPANY
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State Farm Insurance Companies
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INIUU,NC\
June 5, 1995
H,,"iIIIlIlU Service Cenl.,
115 LiUlu~lln Road
P.O. Bult 267
Nuw CUlllhulhmd. Pa 17070.0261
Joyce
Prothonotary's Office
1 Courthouse Square
Carlisle, PA 17013
RE:
CIa im Numbor:
Date of Loss:
Our Insured:
30-6437-144
July 5, 1991
Harold N. Berrier
Dear Joyce:
Per our conversation this morning, here is the envelope I forgot
to send. Ms. Burbon's address is 103 Locust Avenue,
Fredericksburg, PA 17026. If you need anything else, please let
me know. Thank you.
Sincerely,
6 'ltl~j/() rim 011
cathy Hartman
Claim Specialist
(717) 774-9081
State Farm Mutual Automobile Insurance Company
HOME OfficES Ill00MINO rorJ, IlllflOIS 61710000 I
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STATE FARM MUTUAL AUTOMOBILE :
INSURANCE COMPANY, :
Plaintiff :
I
v. I
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 95-3048 CIVIL TERM
TINA M. BURBON, CIVIL ACTION - LAW
Defendant
COMMONWEALTH OF PENNSYLVANIA )
) ss.
COUNTY OF DAUPHIN )
Personally appeared before me, a Notary Publio in and for said
Commonwealth and County, RICHARD H. WIX, ESQUIRE, of the firm of
Wix, Wenger' Weidner, attorneys for the Plaintiff, who being duly
sworn aooording to law deposes and says that the judgment against
the Defendant in the above-oaptioned matter wall entered ae a result
of an automobile acoident oocurring on July 5, 1991
COc:Jl-e Ii )J~
Riohard H. wix, Esquire
Sworn to and subsoribed
before me this..) (,1hday
" of C>t.-\r>\0L'--- , 2000.
\'f\~~~ll. ~ ~ \\u"'_u"o
Notary Publ c
My Commission Expires:
Nol.rlal Seal
l MarCia ^ Chismar, Notary Publl('
MOWesr Pa.ton Twp . Oauphln Cour;l~
omm'"lon . UfO Jail 8 200 I
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