HomeMy WebLinkAbout07-0325
.
ANGINO & ROVNER, P.e.
Richard A. Sadlock, Esquire
Attorney ID#: 47281
4503 North Front Street
Harrisburg, PA 17110-1708
Phone (717) 238-6791
Fax (717) 238-5610
E-mail: rsadlock@angino-rovner.com
Attorneys for Plaintiffs:
Rodney and Shelly Ash for Amanda Ash. a minor
RODNEY AND SHELLY ASH, As
Parents and Natural Guardians of
AMANDA ASH, a minor,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL VANIA
AMICABLE ACTION
v.
CAITLIN SULLIV AN,
Defendant
NO. 67- 3~
e,u~L '--r~
PETITION FOR APPROVAL OF MINOR
PLAINTIFF'S COMPROMISE SETTLEMENT AND
DISTRIBUTION OF PROCEEDS PURSUANT TO RULE 2039
The Petition of Amanda Ash, by her parents and natural guardians, Rodney and Shelly Ash,
respectfully represent:
1. Amanda Ash, the minor Plaintiff, is the daughter of Rodney and Shelly Ash,
Petitioners herein. Amanda Ash is 17 years old having been born on December 30, 1989.
2. Minor Plaintiff, Amanda Ash, resides with her parents, Rodney and Shelly Ash, at 6
Thyme Court, Mechanicsburg, Cumberland County, Pennsylvania.
.
3. On March 9, 2006, Amanda Ash sustained painful and severe injuries which
include, but are not limited to, tom colon requiring surgical repair. Applicable medical records are
attached hereto Exhibit A.
4. A copy of the Police Accident Report is attached hereto as Exhibit B.
5. Defendant Sullivan was insured by Encompass Insurance.
6. The tortfeasors and their insurer have agreed to pay and to compromise the claim
arising from the injuries to Amanda Ash for the sum of One Hundred Twenty Thousand and 00/100
Dollars ($120,000.00), subject to the approval of your Honorable Court. A copy of the letter is
attached hereto as Exhibit C.
7. Petitioner considers this to be a fair, just, and equitable settlement and to be in the
best interests of Amanda Ash.
8. Should the Court deem it necessary to schedule a hearing to approve the settlement,
and if a hearing is scheduled, Minor Plaintiff, her parents, and counsel will be present at the hearing.
9. Your Petitioner has retained the law firm of Angino & Rovner, P.c. to prosecute this
action and has entered into a contingency fee agreement with said attorney whereby said attorney is
to receive, for professional services, thirty percent (30%) of any amount recovered. However,
counsel has agreed to reduce his fee to twenty-five percent (25%) of the amount recovered (or
Thirty Thousand and 00/100 Dollars ($30,000.00)) plus reimbursement of expenses. A copy of the
Fee Agreement is attached hereto as Exhibit D.
345771
2
.
10. To date, Petitioner's counsel has incurred expenses totaling One Hundred Fifty-eight
and 34/100Dollars ($158.34) in pursuit of this claim. An itemized list of expenses is attached hereto
as Exhibit E.
11. After exhaustion of Minor Plaintiff's first-party medical benefit coverage, accident
related medical expenses were paid by HealthAmerica/HealthAssurance. HealthAmerica and
HealthAssurance through ACS Recovery Services has asserted a lien against the instant action.
12. The total lien is Twenty-six Thousand Six Hundred Ninety-six and 95/100
($26,696.95). However, after negotiation, Petitioners' counsel convinced ACS to accept Seventeen
Thousand, Seven Hundred Ninety-one and 301100 Dollars ($17,791.30) to resolve the lien in full.
See January 8, 2007, letter from ACS Recovery Services attached hereto as Exhibit F.
13, There is no child support arrearage owed by Minor Plaintiff, Amanda Ash. See
attached Statement and lien search attached hereto as Exhibit G.
14. Petitioner understands that the remainder of the settlement, after payment of fees,
expenses, is to be held in trust for Amanda Ash in an account which is insured by the Federal
Government and that no withdrawal be made therefrom until Amanda Ash attains majority or
authorized by Court Order.
WHEREFORE, Petitioner respectfully requests Your Honorable Court to approve Minor
Plaintiff's compromise settlement, authorize the payment of attorney's fees and expenses and
reimbursement of the lien from the funds due to the Minor Plaintiff, Amanda Ash, authorize
Petitioners to sign a necessary Release, and direct all remaining funds of Seventy-two Thousand
Fifty and 361100 ($72,050.36) to be deposited in an account which is insured by the Federal
345771
3
..
Government and indicates that no withdrawal be made therefrom until Amanda Ash attains majority
or is authorized by Court Order.
ANGINa & ROVNER, P.C.
Date: January 15, 2007
345771
4
.
PENNSTATE
IS Milton S. ~ Medical Center
., College of Medicine
Patient Name: ASH, AMANDA E
PSUHMC MRN: 7003746
I
D
scharge
Summary
Document
I
Modified
Docwnent Electronically Signed by: Simmons, Lynn G
3/29/20062:29:03 PM
DISCHARGE SUMMARY
Name: ASH, AMANDA E
HMC Number: 742825
DOB: 12/30/1989
Date of Admission: 03/09/2006
Date of Discharge: 03/16/2006
DISCHARGE DISPOSITION: To Home.
HMC ATTENDING MD: Dr. Andreas Meier.
ADMISSION DIAGNOSIS: Multiple trauma from motor vehicle collision.
PRINCIPAL DISCHARGE DIAGNOSIS: Trauma from motor vehicle collision, small bowel perforation, forehead
laceration.
PROCEDURES: Numerous CT scans, exploratory laparotomy, jejunal perforation repair.
BRIEF COURSE OF HOSPITALIZATION: Amanda is a 16-year-old female who came to the Emergency Department
following a motor vehicle collision. She was a restrained, front seat passenger in a side impact collision. Level 2 trauma
activation with ATLS protocol was followed. Initial exam revealed a right forehead hairline laceration, a GCS of 15, and a
seatbelt abrasion. Amanda's chief complaint on admission was abdominal pain. ENT was consulted for primary closure
of her forehead laceration. She was admitted for observation to the IMC. Serial abdominal exams revealed an increase
in abdominal pain. She was taken to the OR on 03/10/06. Initially, a diagnostic laparoscopy, and open repair was
performed for a jejunal perforation. Postop bowel function began to return on 03/14/06; NG was removed and feedings
were begun on 03/15/06. She was hemodynamically stable throughout her hospitalization, ambulated well, and tolerated
a regular diet. She was also voiding well and was discharged on 03/16/06.
DISCHARGE MEDICATIONS:
1. Tylenol with codeine #3, one to two tabs by mouth every 4 hours as needed for pain.
2. Senokot or laxative of choice while taking narcotics to prevent constipation.
ORDERS AND INSTRUCTIONS:
1. Scalp wound care: Please clean wound with half strength peroxide then apply bacitracin three times per day until
suture removal. Keep well protected from sun for 1 year. Watch for signs of infection, fever greater than 101,
redness or pus-like drainage.
2. May shower, dry incisions completely. Steri-Strips will fall off on their own.
3. Please call for any questions or problems - 531-8521 hospital operator, ask for Pediatric Surgery resident on call _
signs of infection listed above, increased pain, nausea, vomiting, or constipation.
Date Printed: 4/19/2006
Time Printed: 5:49 AM
.
PENNSTATE
IS Milton S. He~ Medical Center
., College of Medicine
Patient Name: ASH, AMANDA E
PSUHMC MRN: 7003746
t
D
scharge
Summary
Document
I
Modified
Document Electronically Signed by: Simmons, Lynn G
3/29/2006 2:29:03 PM
4. Please wear your seatbelt at all times while traveling in cars.
FOLLOWUP APPOINTMENTS:
1. ENT - UPC 200. Phone number 531-5215 as needed. Please call if any problems arise.
2. Pediatric Surgery- UPC 3200. Phone 531-8342. 04/05/06 at 3:50 p.m.
#94906
Review/Sign: Lynn G Simmons, CRNP
Review/Sign: Andreas H Meier, MD
Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier,
Kerry FageIman, Brett Engbrecht
Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP CS
Hershey 717-531-8342 HbgiYork 717-920-5200
LGS NSC DD: 03/28/06 DT: 03/28/06 13:48
Date Printed: 4/19/2006
Time Printed: 5:49 AM
.
PENNSTATE
IS Milton S. ~ Medical Center
., College of Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, P A 17033-0850
Tel: (717)531-8055
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
ASH, AMANDA E
Female
7MBE, 7227, 01
Inpatient
PSUHMC MRN: 7003746
Date of Birth: 12/30/1 989
Visit Number: 6503318
Ope rat
v e
Not e
Document
,
Final
Document Electronically Signed by: FageIman, Kerry M
3/20/200612:33:34 PM
OPERATIVE REPORT
Name: ASH, AMANDA
HMC Number: 7003746
DOB: 12/30/1989
Date of Service: 03/10/2006
SURGEON: Fagelman and Bradburn.
ASSISTANT(s):
PREOPERATIVE DIAGNOSIS: Possible intestinal injury.
POSTOPERATIVE DIAGNOSIS: Jejunal perforation.
OPERATION PERFORMED: Diagnostic laparoscopy with open repair of jejunal perforation.
ANESTHESIA: General.
INDICATIONS: The patient is a 16-year-old female who yesterday was involved in an automobile accident as a
passenger. She was wearing her seatbelt, and there is obvious seatbelt contusion across the abdomen. A CT scan
performed at the time of admission showed some free fluid in the pelvis, but no evidence of any obvious injury. Today, on
repeated examination, there was deterioration in her physical exam with evidence of developing peritonitis. On that basis,
despite the patient was stable and appeared otherwise healthy, it was felt necessary to proceed with diagnostic
laparoscopy to determine if there was a devascularized segment of intestine or possible even a missed bowel perforation.
With the CT scan showing an excellent view of the upper abdomen, it was not felt necessary to examine the liver, spleen,
stomach, pancreas, or duodenum, but to examine primarily the small intestine and what could be visualized of the large
intestine, and especially its mesentery.
OPERATION: With the patient in the supine position under suitable general endotracheal anesthesia, the abdomen was
prepped and draped in the usual fashion. Quarter percent Marcaine with epinephrine was injected at the undersurface of
the umbilicus where a small incision was made, and dissection was done down along the umbilical fascia to the linea alba.
The umbilical fascia was slightly separated from the linea alba creating a small rent in the fascia with entrance into the
peritoneal cavity. With traction sutures of 0 Vicryl placed on either side of this opening, a 5 mm port was placed in the
Date Printed: 4/19/2006
Time Printed: 5:49 AM
.
PENNSTATE
IS Milton S. ~ Medical Center
., College of Medicine
Patient Name: ASH, AMANDA E
PSUHMC MRN: 7003746
~
Ope rat
v e
Not e
Document
I
Final
Document Electronically Signed by: Fagelman, Kerry M
3/20/200612:33:34 PM
abdomen insufflated to 15 mmHg of pressure. She was placed in slight Trendelenburg. Two additional ports were
placed, one in the left mid abdomen, one in the right upper quadrant area with the intent of using these to run the small
intestine. These ports were placed with quarter percent Marcaine with epinephrine being injected at the skin and down to
the peritoneal level. An incision was made and the port placed under direct vision. It proved easier to place the camera in
the right upper quadrant port and the other two ports were used for manipulation. The blood down in the pelvis was
aspiration, and then the pelvic organs were examined. The ovaries appeared to be normal. There was no evidence of
any ruptured cysts of either structure. The terminal ileum was then identified and elevated, and the small bowel was
gradually run proximally. It appeared perfectly normal until the area of the proximal jejunum. There was an area of
probably about 20 to 30 cm in length where there was petechia and ecchymosis on the wall of the jejunum, but no
evidence of any injury at this site. Proximal to this, there was a normal segment of bowel followed by another segment
where, again, there was petechia and ecchymosis. At this site, there was, indeed, a perforation identified adjacent to the
mesentery. The decision was made to perform an open repair of this site. What could be seen of the large intestine
appeared to be normal. Subsequently, the abdomen was desufflated, and the ports and instruments were removed. A
midline incision was made from the umbilical site superiorly to approximately one-third or one-half of the linea alba above
the umbilicus. Upon entering the peritoneal cavity, the jejunum was directly under the area of the incision, was easily
elevated, and the perforation visualized. There was a small amount of exudative material on the surface. There was no
evidence of any spillage of intestinal contents. The mesenteric leaf on this side of the jejunum was taken down so as to
expose the mesenteric portion of the perforation. These vessels were simply cauterized and achieved hemostasis. The
perforation was closed in a transverse fashion in two layers with an inner layer of running locking 4-0 Vicryl and an outer
layer of inverting interrupted 4-0 silk. It was possible to express fluid from the proximal part of the jejunum past this area
without any evidence of leakage. It is estimated that this site is about 30 cm from the ligament of Treitz. Because the CT
scan showed no evidence of injury to the duodenum, the upper abdomen was not explored. The small bowel was again
visualized by open inspection as was the transverse colon and all of it appeared to be normal. The small bowel was put
back into its normal position, copious irrigation was done of the peritoneal cavity, and then the linea alba was
approximated with interrupted simple sutures of 0 Vicryl. The skin was approximated with interrupted simple sutures of 3-
o nylon as well as at each of the two 5 mm port sites. The wounds were cleansed and dressed with gauze covered by
tape. She tolerated the procedure well. Sponge, needle, and isntrument counts were correct, and she was returned to
the Recovery Room in satisfactory condition. I was present throughout the entire length of the operation.
Date Printed: 4/19/2006
Time Printed: 5:49 AM
PENNSTATE
!!II Mil.. ton 8.. ~ Medical Center
., College of 1\fedidne
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, P A 17033-0850
Tel: (717) 531-8055
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
ASH, AMANDA E
Female
PESU, ,
Clinic
PSUHMC MRN: 0742825
Date of Birth: 12/30/1989
Visit Number: 6569203
I
Out pat
e n t
Letter
Document
I
Final
Document Electronically Signed by: Cilley, Robert E
4/10/20068:31:50 AM
OUTPATIENT LETTER
April 6, 2006
Name: ASH, AMANDA E
HMC Number: 0742825
DOB: 12/30/1989
Date of Service: 04/06/2006
Katherine Gallagher-Shrift, M.D.
204 Mumper Lane
Dillsburg, PA 17019
Dear Dr. Gallagher-Shrift:
We saw Amanda and her dad in followup after her recent motor vehicle crash where she sustained a number of injuries. She is now
nearly 4 weeks out from injury. At that time, she sustained a mild closed head injury, a large scalp laceration, which was repaired, and
a small bowel burst injury requiring laparoscopic assessment and mini laparotomy repair. She had an uneventful recovery and
completed a course of antibiotics with a subsequent discharge from the hospital. Since she has been home, she has had no sequelae of
closed head injury. She has had no personality changes. She is back in school and has observed no effect in her school performance.
She is not having any headaches. Her scalp laceration is nicely healed, and she has had a followup appointment with
otolaryngology/fascial reconstruction surgeons. She is eating well, having no nausea or vomiting, and normal bladder and bowel
function.
Weight: 51.3 kg. Lungs are clear. Abdomen is soft and nontender. Port sites are nicely healed. Her umbilical port site was extended
into a supraumbilical incision and it is nicely healed. On further questioning, Amanda is very upset with the alteration of the left side
of her umbilicus as a result of her incision. Although, somewhat subtle and not at all unsightly by my initial inspection, it has a very
Date Printed: 10/2012006
Time Printed: 6:18 AM
PENNSTATE
IS Milton s.~ Medical Center
. College of1\fediclne
Patient Name: ASH, AMANDA E
PSUHMC MRN: 0742825
I
Out pat
e n t
Letter
Document
,
Final
Document Electronically Signed by: Cilley, Robert E
4/10/20068:31:50 AM
different appearance from the very flat oval-appearing umbilicus that she had preoperatively. This is actually what is upsetting her the
most and caused quite a bit of emotional distress to discuss.
Amanda has had an uneventful recovery from her physical injuries. All her wounds are healing nicely, and we are quite pleased that
she suffered no consequences from this very serious injury. The concern about the appearance of her umbilicus is a real one for her.
We did some photogr~phic documentation today. I think that she may get some scar remodeling and shrinkage to give her a little
more natural appearance. I would like to see her in 6 months, and we can reassess using the photographic documentation to decide
whether anything should be done further with her umbilicus. I think she was happy that we were able to discuss this openly. Her
father attended her, and we indicated that we would look forward to seeing her in 6 months. Call us if there are questions or
developments of which we should be aware.
116457
CC: Katherine GallagherShrift, MD
204 Mumper Lane
Dillsburg, P A 17019
*
Sincerely,
Robert E Cilley, MD
Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier,
Kerry FageIman. Brett Engbrecht
Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP CS
Hershey 717-531-8342 HbgN ork 7! 7 -920-5200
REC ICD DD: 04/06/06 DT: 04/07/06 06:45
Date Printed: 10120/2006
Time Printed: 6:18AM
.
PENNSrATE
!S Milton s.~ Medical Center
., Conege of l\fedicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Tel: (717) 531-8055
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
ASH, AMANDA E
Female
PESU"
Clinic
PSUHMC MRN: 0742825
Date of Birth: 12/30/1989
Visit Number: 7461705
Out pat
e n t
Letter
Document
I
Final
Document Electronically Signed by: Meier, Andreas H
9/28/2006 4:40:54 PM
OUTPATIENT LETTER
September 20,2006
Name: ASH, AMANDA E
lIMe Number: 0742825
DOB: 12/30/1989
Date of Service: 09/20/2006
Katherine GallagherShrift, M.D.
204 Mumper Lane
Dillsburg, PA 17019
Dear Dr. GallagherShrift :
We saw Amanda in our clinic today in followup for her motor vehicle accident, which she suffered early this year. She had suffered a
jejunal perforation, which was repaired. She has had some concerns about the appearance of umbilicus on her postoperative visit.
This was about 6 months ago. She now returns to us without any significant problems. She states that appearance of her umbilicus
has markedly improved. On physical exam, she has slightly widened scar just above the umbilicus. The umbilicus is otherwise within
normal limits.
Impression: Amanda seems to be doing well, and her problem with the umbilicus has improved. At this point, no further intervention
is necessary. However, we are always available in case that she wants us to reexamine the scar.
Once again, thank your for allowing us to assist in her care. Please call us with any questions.
Date Printed: 10120/2006
TIme Printed: 6:18 AM
Print CRS W0035876
Page 1 of7
,
.J COIIIIMONWEALTH Of PENNSYLVANIA 1111111111111111111111111 I
POLlCIE CRASH RIEPORTlNG fORM Crash Number
Case Closed Reportable Crash Lb W0035876
'Ak500 1 o Y~s 0 No o Yes 0 No
Incident Number Polke Agency Patrol Zone
f I HAM2006-03-00298 II 21103 I l100 I
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to I Hampden Township II I 03 D~D12006 I
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II!. ISGT SHAUN A. FELTY 1119-2 I 04 D~D12006 I
EJou County Name runicipality I Municipality Name Dav of WINk
21 ICumberland I 103 luampden Township I 0 Sun 0 Thu
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Crash Date (MM-DD-YYYY) I Crash Time (mil) I NOO of Units I People I Iniured ~Killed* *If> 00 0 Tue 0 Sat
r;.;--, I U I 15 0 complete
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Workzone (If Yes, Complete 0 Yes 0 No I School Bus 0 Yes 0 No I School Zone 0 Yes 0 No Notify PENNDOTO Yes 0 No
Form M, SeCtion 29) Related Related Maintenance
Intersection TI(p@ 04 Way Intersection 0 'V' Intersection 0 ~~~~~on 0 Off Ramp 0 Railroad Crossing
o Midblock 0 T Intersection 0 ~~:~ ~~~ 0 On Ramp 0 Crossover 0 Other
Route Number Segment (Optional) Travel Lanes Speed Limit 0 North
1001l II I ~ ~ a o South
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2
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House Number (if applicable)
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For Mid-block crashes only. Use
postal House Number and make sure
Principal Roadway Street Name is
filled in if using this option
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Intersecting Rt Num Or Mile Post Or Segment Marker
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~ Or Intersecting Street Name
31
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; Lane C1mw/ (If "Not Applicable", s1cip rest of the Lane Closure section) I lamP c:Jarun.
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o Device Not 0 Device Functioning 0 Unknown
Functioning Properly
0 North 0 East o North and South 0 All
0 South 0 West o East and West (N,S,E,Wl
o 6-9 hrs 0 > 9 hours 0 Unknown
FORM . AA-SOO (12102)
--.------
._--- -- ---.--.
PENNDOT COpy
http://www.dot6.state.pa.us/icons/Printlmages/XmIFiles/20060267911 sheetz 19172006041... 4/12/2006
Print CRS W0035876
Page 2 of7
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W0035876
10
~ ~ o Motor Vehicle in a Hit & Run Vehicle a Illegally Parked a legally Parked 0 Non - Motorized Commercial Vehide
Transport
Y!l!$. o Pedestrian a Pedestrian on Skates, a Disabled From o Train a Phantom Vehkle o Yes o No
! in Wheelchair, etc Previous Crash (If Yes, Complete Form C)
(If 'Pedestrian" or 'Pedestrian on Skates, in Wheelchair, etc', Comolete Form M, Section 28)
Unit No First Name MI Date of Birth (MM-DD- YYYY)
EJ I CAITLIN I @J ~ ~ I 1989 I
Delete? Last Name Telephone Number
0 I SULLIVAN I 1 7177326566 I
Address I City I State Zip
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I Normal Use
o Alcohol a Alcohol and Drugs o Unknown o Had Been a Sick 0 Asleep 0 Unknown
- Drinking
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.~ o Test Not Given a Breath a Other Charged?
a IVEHICLE TURNING LEFT (SEC I ayes
.. o Blood a Urine a Unknown if aNo
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II Alcohol Test Results a Test Refused a Unknown Driver Presence 1 =Driver Operated 3=Driver Fled Scene
> Results --L
[Q].D a Test Given, [] Vehicle 4=Hit and Run
Contaminated Results 2=No Driver 9=Unknown
OwnerlDrlver OO=Not Applicable 02=Priyate Vehicle Not 04=State Police Vehicle 07=Munidpal Police Veh 09=Federal GOY Veh
EJ 01 ",Private Vehicle Owned! OWnedILeased by Driver 05",PENNDOT Vehicle OS",Other Municipal 98=Other
leased by Driver 03",Rented Vehicle 06=Other Slate GOY Veh Government Vehicle 99",Unknown
Same as I Owner First Name Owner Last Name or Business Name (If Pedestrian, skip this Section)
Driver a I SHELL Y E I lASH I
Address I City I State I Zip Vehide Make *l\Ilake Code
I 6 THYME CT MECHANICSBURG P A 17050 II Honda I~
VIN Model Vear Vehide Model (see overlay)
11GNDM19WIPB1l3397 II 1998 I I ACCORD I
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I GHD9756 I~ 1025 I a Yes a No I ROADSIDE AUTO R I
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Vehide Color Vehicle TVDe OS=Large Truck 20",Unicycle, Bicycle, 12=Commercial
~ 06",Yellow ~ 01=Automobile 06=SUV Tricycle Passenger
07=Silver 02=Motorcycle 07=Van 21 =Other Pedalcycle OO=Not Applicable Carrier
01=Fire Veh 13", Taxi
OS:Gold 03=Bus 10=Snowmobile 22",Horse & Buggy 02"'Ambulance 21"'Tractor Trailer
01 "'Blue 09=Brown 04=Small Truck 11 =Farm Equip 23=Horse & Rider 03=Police 22= Twin Trailer
02=Red 1000range (If -02-, Complete Form 12",Construction Equip 24",Train OS",Other Emergency 23= Triple Trailer
03",White 11 =Purple M, Section 26) 13=ATV 25=Trolley Vehicle 31 =Modified Veh
04",Green 12=Other (If "20- or -21 -, Complete lS=Other Type Spec Veh 9S",Other II=Pupil Transport 99=Unknown
05",Black 99=Unknown Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown
In/tlallmDact Point Damatle Indicator ~ 3=Downhill Road AliQnment
~ OO=Non-Collision 14=Undercarriage [IJ O=None 2"'Functional IT] 1 ",level 4=Bottom of Hill Q] 1 =Slraight
01-12=Clock Points 15=Towed Unit I=Minor 3"'Disabling 2=Uphill 5=Top of Hill 2",Curved
13",Top 99=Unknown 9",Unknown 9",Unknown 9",Unknown
-
FORM' AA-500 (12.()2)
PENNDOT COpy
11
12
http://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/20060267911 sheetz19172006041". 4/12/2006
Print CRS W0035876
Page 3 of7
AA 500 2 I Po,ce Use Only
Page:
I [~]
111111111I IIIIII
Crash Number --,
~
CIQl~lMiIlOli\'lWtE6l.8. ii'&{) OIF PlEIMlMsn V ANB~
~ILICIE aASH IRElPO~RING FORIMl
10
~ ~ o Motor Vehicle in 0 Hit & Run Vehicle 0 Illegally Parked o Legally Parked 0 Non. Motorized Commercial Vehicle
Transport o Yes o No
!t!l!! o Pedestrian o Pedestrian on Skates, 0 Disabled From o Train o Phantom Vehicle
in Wheelchair, etc Previous Crash (If Yes. Complete Form C)
(If 'Pedestrian" or 'Pedestrian on Skates, in Wheelchair, etc., Comolete Form M, Section 18)
Unit No First Name MI Date of Birth (MM-DD.YYYV)
~ I SHELLY I ~ ~ EJ I 1963 I
Delete? Last Name Telephone Number
0 lASH I I 7177666459 I
c: Address I City I State Zip I
I 16 THYME CT MECHANICSBURG PA 1117050
Driver License Number State Class
120723464 I~~ I
oS
c:
i AlcohoVDruqs SusDeCted Driver or Pedestrian Phvsical Condition
aNo o Illegal Drugs o Medication o APparently o Illegal Drug 0 Fatigue 0 Medication
Normal Use
l o Alcohol o Alcohol and Drugs o Unknown o Had Been o Sick o Asleep 0 Unknown
- Drinking
..
,~ Alcohol Test TVDe PrimaIV Vehicle Code Violation Charged?
.. o Test Not Given o Breath o Other
Q I I ayes
. o Blood o Urine o Unknown if aNo
'ti
! Test Given
Alcohol Test Results o Test Refused o Unknown Driver Presence 1 =Driver Operated 3=Driver Fled Scene
Results --L
[Q].D o Test Given, [] Vehicle 4=Hit and Run
Contaminated Results 2=No Driver 9=Unknown
Owner/Driver OO=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Munidpal Police Veh 09=Federal Gov Veh
@C1 01 =Private Vehicle Owned! OwnedlLeased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other
leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown
Same as I OWner First Name OWner Last Name or Business Name (If Pedestrian, skip this Section)
Driver 0 I SHELL Y E I lASH I
Address I City I State I Zip Vehicle Make *Make Code
16 THYME CT MECHANICSBURG PA 17050 II Chevrolet I~
VIN Model Year Vehicle Model (see overlay)
IIGNDMI9WIPBI13397 II I I ASTRO I
License Plate Reg. State Est. Speed Vehicle Towed Towed By
I GHD9756 I~ 1040 I o Yes 0 No I ROADSIDE AUTO R I
~ Insurance Company Policy No
c: aYes aNo o ~~~wn I ERIE INSURANCE EXCHANG II Q021903546H I
0
:a;
~ Trailino l=Towing Pass. Veh 4=MobilelModular Home 7=Semi-Trailer Tag No Tag Year Tag St
2 0 rr:,:
s Unit No. of @] D 2=Towing Truck 5=Camper 8=Other I II ID
" - Trailing 3= Towing Utility Trailer 6=Full Trailer 9=Unknown
'ti Units:
J! .Vehicle Position ~ .Movement @C1 *See
:t Direction of ~ SDecial Usaqe
Travel Overlay @O
Vehicle Color Vehicle TVDI 05=large Truck 20=Unicycle, Bicycle, 12=Commercial
Passenger
~ 06=Yellow ~ 01=Automobile 06=SUV Tricycle OO=Not Applicable Carrier
07=Silver 02=Motorcycle 07=Van 21 =Other Pedalcycle 01 =Fire Veh 13= Taxi
08=Gold 03=Bus 10=Snowmobile 22=Horse & Buggy 02=Ambulance 21=Tractor Trailer
01=Blue 09=Brown 04=Small Truck 11 =Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer
02=Red 1000range (If "01-, Complete Form 12=Construction Equip 24= Train 08=Other Emergency 23= Triple Trailer
03=White 11 =Purple M, Section 16) 13=ATV 25=Trolley Vehicle 31=Modified Veh
04=Green 12=Other (If "20. or -1/., Complete 18=Other Type Spec Veh 98=Other 11 =Pupil Transport 99=Unknown
05=81ack 99=Unknown Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown
InitlallmDllct Point Damaqe Indicator Gradient 3=Downhill Road Alianment
~ OO=Non-Collision 14=Undercarriage ~ O=None 2=Functional QJ l=leve' 4=Bottom of Hill [2] 1 =Straight
OH2=C1ock Points 15=Towed Unit 1 =Minor 3=Disabling 5=Top of Hill 2=Curved
13=Top 99=Unknown 9=Unknown 2=Uphill 9=Unknown 9=Unknown
-
W0035876
11
FORM. AA-500 (1.w2)
PENNDOT COPY
http://www.dot6.state.pa.us/icons/Printlmages/XmIFiles/20060267911 sheetzI9172006041... 4/12/2006
Print CRS W0035876
..J
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 3 I POlice Use Only
Person we:
A 1 =Driver
2=Passenger
7=Pedestrian
8=Other
9=Unknown
Ii:
o
..
Ii
~
J!
=
"
a.
o
1.
~:
B f =female
M =Male
U =Unknown
Iniury Severity:
C Q;Not Injured
I=Killed
2=Major Injury
3=Moderate
Injury
4=Minor Injury
8=lnjury, Unk
Severity
9=Unknown if
Injury
Seat Position'
D OO=Not A PassengerlOccupant
01 =Driver - All Vehicles
02=front Seat Middle Position
03=front Seat Right Side
04=Second Row - left Side Or
Motorcycle Passenger
05=Second Row - Middle Position
06=Second Row - Right Side
07=Third Row Or Greater-
left Side
08= Third Row Or Greater -
Middle Position
09= Third Row Or Greater -
Right Side
10"Sleeper Section of Truckcab
11 =In Other Enclosed
Passenger Or Cargo Area
12=ln Open Area
(Back Of Pickup, Etc.)
13= Trailing Unit
14=Ridin9 On Vehicle Exterior
15=Bus Passenger
98=Other
99=Unknown
Page
IU
Safety Eauinment One:
E OO=None Used I Not Applicable
01 =Shoulder Belt Used
02:lap Belt Used
03"lap And Shoulder Belt Used
04=Child Safety Seat Used
05=Motorcycle Helmet Used
06=Bicycle Helmet Used
10=Safety Belt Used Improperly
11 "Child Safety Seat Used Improperly
12=Helmet Used Improperly
90=Restraint Used, Type Unknown
99=Unknown
Safety Eauinment Two:
F OO=None Used I Not Applicable
01 :front Air Bag Deployed (For This Seat)
02=Side Air Bag Deployed (For This Seat)
03=Other Type Air Bag Deployed
04=Multiple Air Bags Deployed
05=Motorcycle Eye Protection
06=Bicyclist Wearing ElbowlKneelPads
10=Air Bag Not Deployed, Switch On
11 =Air Bag Not Deployed, Switch Off
12=Air Bag Not Deployed,
Unk Switch Setting
13=Air Bag Removed (Prior To Crash)
19=Unknown If Air Bag Deployed
99=Unknown
3 EMS Agency: I HAMPDEN TWP. & ASSIS
Page 4 of7
'"1111111I11111
Crash Number --,
W0035876
~:
G O=Not Applicable
1 =Not Ejected
2= Totally Ejected
3"Partially Ejected
9=Unknown
H Eiection Path:
O=Not Ejected I Not Applicable
1 = Through Side Door Opening
2= Through Side Window
3= Through Windshield
4= Through Back Door
5= Through Back Door Tailgate Opening
6= Through Roof Opening (Sunroofl
Convertible Top Down)
7= Through Roof Opening (Convertible
Top Up)
9=Unknown
/-
~:
I O=Not Applicable
1 =Not Extricated
2=Extricated By Mechanical Means
3=Freed By Non - Mechanical Means
8:0ther
9=Unknown
I Medical Facility: I HERSHEY MEDICAL CENTER & HOLY SP
Unit No Person No Delete? Date of Birth (MM-DD-YYYY)
~ ~ 0 ~-EJ-11989
Name I Address I Phone
o Same as IDONALD SUMPLE CODY KS
Operator
Unit No Person No Del 7 Date of Birth (MM-DD-YYYY)
DO ote 0-0-1
Name I Address I Phone
o Same as I
Operator
Unit No Person No 0 I ? Date of Birth (MM-DD-YYYY)
~@CJ ate ~-~-11989
Name I Address I Phone
o osame as 'SULLIVAN, CAITLIN D 1019 N W A TERFORD WAY MECHANICSBURG P
perator I
ABC D E F GH r
I[O[J~@CJ~EJEJ@][J
I EMS Transport
aVes 0 No
ABC D E F GH I
I[]~EJ~~@CJ[J@][J
I EMS Transport
aVes aNo
Unit No Person No 0 I 7 Date of Birth (MM-DD-YYYY)
~ ~ ate ~-~ -11963
Name I Address I Phone
o soame as I ASH, SHELLY E 6 THYME CT MECHANICSBURG P A 17050 71776664
perator I'
ABC D E F GH r
I[][J[]~~~EJ@][]
I EMS Transport
aVes 0 No
Unit No Person No D I ? Date of Birth (MM-DD-YYYY)
~~ ate ~-EJ-11989
Name I Address I Phone
Dosametas IAMANDA ASH 6 THYME CT. MECHANICSBURG PA 170507177666459
pera orl'
ABC D E F GH r
I[]~[]~~~ITJ@][J
I EMS Transport
aVes 0 No
Unit No Person No I ? Date of Birth (MM-DO-YYYY)
~ ~ Dote ~-EJ -11991
Name I Address I Phone
Do sameatas I MICHAEL ASH 6 THYME CT. MECHANICSBURG PA 17050717766645
per or I
FORM' AA-5OO (12102)
ABC DE F GH I
I[D~EJ~~~ITJ@]ITJ
I EMS Transport
aVes aNo
ABC D E F GH I
IDDDDOODDD
PENNDOT COpy
I EMS Transport
aVes aNo
http://www.dot6.state.pa.us/icons/PrintImages/XmIFiles/20060267911sheetzI9172006041". 4/12/2006
Print CRS W0035876
.J
COMIViONWIEAlTH Of PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 4 I Police Use Only
Page
I [C]
W0035876
Page 5 of7
111111111I111111
Crash Number
-,
Cmh Desailltion ~ O=Non-Collision 2=Head On 4=Angle 6=Sldeswipe 8=Hlt Pedestrian
1 =Rear End 3=Rear to Rear ~=IBE;l . (Opposite Direction)
c~ (Backing) IrectiOn) 7=HR Fixed Object 9=Other/Unknown
,2 ~
~ ! Relation to Roadwav IT] 1 =On Travel Lanes 3=Medlan 5=Oulside Trafficway 7=Gore (Ramp Intersection) ~
.2 a 2=Shoulder 4=Roadside 6=ln Parldng Lane 9=Unknown
~ f III . ti - - 1
15 [] 1 =Daylight 3=Dark - Street 5=Dawn B=Other
~" umma on 2=Dark i [jgt Ughts 6=Dark . Unknown
III " Street . hts 4=Dusk Roadway lighting
.. ::l
VN -- - -~
'!i Weather Conditions [] 1 =~ A~erse 3=Sleet (Hail) 5=Fog 7=Sleel & Fog 9=Unknown
II . nclitions
~ ~ 2=Raln 4=Snow 6=Rain & Fog 8=Other
~ -, .-=-=-- --J
~ O=Dry 2=&and, Mud, Dirt, 4=Slush 6=lce Patches B=Other
'" Road Surface Conditions l=Wet 5=lce 7=W~r : Standing
3=Snow Covered or oVlng _ _ =
Harm Event L1R Most? UtilitYPole Number -.
Harmful Events (Harm Event) 30=Hit Fence Or Wall
1 ODO 0 I I 01 =Hit Unit 1 31=Hit Building
Unit No 02=Hit Unit 2 32=Hit Culvert
03=Hit Unit 3 33=Hit Bridge Pier Or Abutment
EJ200 0 I I 04=Hit Unit 4 34=Hit Parapet End
05=Hit Unit 5 35=Hit Bridrce Rail
06=Hit Other Traffic Unit 36=Hit Bou der Or Obstacle
Please ~t 3 0 0 I I 07=Hit Deer On Roadway
0 08=Hit Other Animal 37=Hitlmpact Altenuator
Events m 09=Collision With Other Non 38=Hit Fire Hydrant
Sequential
Order 4 0 0 I I Fixed Object 39=Hit Roadway Equipment
C 0 11 =Struck By Unit 1 40=Hit Mail Box
0 12=Struck By Unit 2 41=Hit TraffIC Island
i
16 E 13=Struck By Unit 3 42=Hit Snow Bank
Harm Event L1R Most? Utility Pole Number 14=Struck By Unit 4 43=Hit Temporary Construction
,g 15=Struck By Unit 5 Barrier
~ EJO I I 4B=Hit Other Fixed O~ect
.. 1 0 16=Struck By Other T rafflc Unit
c Unit No 21=Hit Tree Or Shrubbery 49=Hit Unknown Fixe Object
II
> 22=Hit Embankment 50::0verturnIRoII Over
... ~20D I I 23=Hit Util~ Pole 51 =Struck By Thrown Or Falling
- 0
1ft 24=Hil Trat IC Sign Object
:E
c 25=Hit Guard Rail 52=Pot Holes Or Other
:::l I I 26=Hit Guard Rail End Pavement Irregularities
Please P~ 3 0 0 0 27=Hit Curb 53=Jacknife
Events In 28=Hit Concrete Or 54=Fire In Vehicle
Sequential
Order 40D I I Longitudinal Barrier 58"Other Non-Collision
0 29=Hit Ditch 99=Unknown Harmful Event
17
First
Rimtful
Event m
tM crash
Unit No Harm Event
~EJ
Unit No Harm Event
~EJ
Most
RMmful
Eventm
tM Oash
Do not repeal this information on multiple pages
18
Environmental I Roadwav
Potential Factors (EIR) 1
OO::None
01 =Windy Conditions
02=Sudden Weather Conditions
03=Other Weather Conditions
04=Deer In Roadway
OS"Obslacle On Roadway
06=Other Animal In Roadway
07=Glare
08=Work Zone Related
~ 20 30
11 =Slippery Road Conditions (lceJSnow)
12=Substance On Roadway
13=Potholes
14=Broken Or Cracked Pavement
15= TeD Obstructed
16=Soft Shoulder Or Shoulder Drop Off
28=Other Roadway Factor
29=Other Environmental Factor
99=Unknown
c
o
'i Possible Vehide Failures (V)
E OO=None 06=Exhaust
,g 01=lires 07=Headlights
~ 02=Brake System 08=Signal Lights
g' 03=Steering System 09=Other Lights
;; 04=Suspension 10=Horn
il OS=Power Train 11=Mirrors
'C
..
C
o
IJ
12=Wipers
13"Driver Seating/Control
14=Body, Doors, Hood. Ett
1 S= Trailer Hitch
16=Wheels
17:Airbags
18= Trailer Overloaded
19=UnsecureJShifted
Trailer Load
20=lmproper Towing
21 =Obstructed Windshield
99=Unknown
~~k~1~20
~~it~1~20
Indicated Prime Factor Unk No Factor Code
00 not repeat this information on ~~
19 multiple pages.
EIR V D II
0 0 0 0 If fIR is the Prime Factor
Type, leave Unit No blank
FORM' AA-5OO {12Al2)
PENNDOT COpy
Driver Action (0)
OO=No Contributing Action
01=Driver Was Distracted
02=Driving Using Hand Held Phone
03=Driving Using Hands Free Phone
04=Making Illegal U-Turn
05=lmproper/Careless Turning
06= Turning From Wrong Lane
07=Proceeaing WIO
Clearance After Stop
08=Running Stop Sign
09=Running Red light
1 O=Failure To Respond To
Other Traffic Control Device
11=Tailgating
12"Sutfden SlowinQl'Stopping
13=lIIegally Stoppea On Roai:t
14=Careless Passing Or Lane
Change
IS=Passing In No Passing Zone
16=Driving The Wrong Way On
I-Way Streel
~~ltEJ 1 EJ 20 30.40
~~it~ 1~203040
Pedestrian Action (PJ
OO=None
01=Entering Or Crossing At
Specified Location
02=Walki"9' Running, Jogging,
Or PlaYing
Unit NO~
17 =Careless Or Illegal
Backing On Roadway
18=Driving On The Wrong
Side Of Road
19=Making Improper
Entrance To Highway
20=Making Improper EXIt
From Highway -1
21 =Careless ParkinglUnparking
22=OVer/Under
Compensation At Curve
23=Speeding
24=Oriving Too Fast For Conditions
25=Failure To Maintain Proper Speed
26"Driver Fleeing Police (Pol Chase)
27 =Driver Inexperienced
28=Failure To Use Specialized Equip
92=Affected 8y Physical Condition
98=Other Improper Driving Actions
99=Unknown
03=Working
04=Pushing Vehicle
05=Approaching Or Leaving Vehicle
06=Working On Vehicle
07=Standing
98=Other
99=Unknown
~ UnitNo~ ~
http://www.dot6.state.pa.us/icons/PrintImages/XmlFilesI20060267911 sheetzI9172006041... 4/12/2006
Print CRS W0035876
Page 60f7
-.J
Page
I CO
111111111I11111111
Crash Number -,
COMMONWEALTH OF PENNSYLVANIA
POUCE CRASH REPORTING FORM
AA 500 5 I Police Use Only
W0035876
. .
. .
. .
. . ,
" . .
. . . . . . . . . . . . . . . . . . . . . . . . .
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o
Witness Name
Address
Phone
1
2
Narrative and additional witnesses:
Accident Investigation Notification lssued1 0 Property Damage 0
Unit 2 was Westbound on the Carlisle Pike under a green signal. Unit 1 was
turning left to Skyport Road from the Eastbound turn lane under a green signal
with a yield. Unit 2 crossed into the path of Unit 2. Unit 2 struck Unit 1
Severe damage. Driver and R/F passenger of Unit 2 transported by helicopter to
Hershey Med. Trauma Center. UCenter passenger of Unit 2 transported to Hershey
by EMS. Driver and R/F passenger of Unit 1 transported to Holy Spirit Hospital
by EMS. Both units towed by Roadside Auto Rescue
.
>
~
II
Z
1
.
22 ;
~
i
FORM' AA-!GO (12/02)
PENNDOT COpy
http://www.dot6.state.pa.us/icons/PrintImages/XmIFilesI20060267911 sheetz 19172006041... 4/12/2006
Print CRS W0035876
Page 70f7
Crash Number: W0035876
Incident Number: HAM2006-03-00298
WENDY'S
o
0::
I ~ I
Q..
I ~ I
Unit 2
II
I! CARLISLE PIKE
TTO .seAL
PEP BOYS
CD
http://www.dot6.state.pa.us/icons/PrintImages/XmIFiles/20060267911 sheetz 19172006041... 4/12/2006
Page 1 of2
Synopsis
[
Close.Window
"
@ Quality Assurance Synopsis 0 Report
Crash Synopsis created 04/12/2006 for Crash Number W0035876 Web Group: QA.
Police Agency Data:
The crash report was recorded by police agency 21103-Hampden Township, patrol zone - 100, under incident number HAM2006-03-00298.
The dispatch date was 03/09/2006, the dispatch time was 2031 hours, the investigation date was 03/0912006, the arrival time was 2038 hours.
The investigator was CPL. THOMAS SPECK, badge number 19-6. The report was approved by SGT SHAUN A. FEL TV, badge number 19-2
on 04/0712006.
Crash Data:
This angle crash occurred in Cumberland county, in the municipality of Hampden Township, on Thursday, 03/09/2006 at 2031 hours. The
illumination at the time of the crash was dark with street lights. The 2-unit crash involved 5 people with 5 injuries. There were no fatalities. This
is a reportable crash. Highway maintenance was not notified. The crash was not school bus related. The crash was not school zone related.
There was no PennDOT property damaged. The crash did not occur in a work zone. The roadway surface was dry. Weather conditions
included No adverse conditions. A notification of an accident investigation was not issued. Other environmental/ roadway potential factors
included None. The indicated prime factor for this crash was a driver's action (making an improper / careless turn) for unit 01. The first and
most harmful event for this crash was that unit 2 Hit unit 01.
Type Location:
This was a four way intersection crash, which occurred at no special location.
Principal Roadway:
Cumberland County, route 0011, the orientation of the roadway was East, there were 04 travellane(s), the speed limit was 40 Mph, with State
highway route signing.
Intersecting Road:
Cumberland County, SKYPORT Road, the orientation of the roadway was North, there were 02 travellane(s), the speed limit was 35 Mph,
with Local road or street route signing.
TCD:
Traffic Control Device: a traffic signal, functioning properly.
Work zone:
Type of Work Zone: not a work zone.
Lane Closure:
Fully closed. Lane closure direction West. Traffic detoured yes. Estimated hours closed 1-3 hours.
UNIT INFORMATION: 1
Unit Number 1 was a motor vehicle in transport. The unit was owned by SHELLY E ASH. Address: 6 THYME CT, MECHANICS8URG, PA
17050. This 1998 Honda identified by VIN: 1GNDM19W1P8113397 was registered in PA with License GHD9756. Travel speed: 025. Unit
insured: vehicle has insurance, Insurance Company: ENCOMPASS INSURANCE CO., Policy number: 211146139. The Unit was towed by
ROADSIDE AUTO RESCUE. This was not a commercial vehicle. This Unit was an automobile, Vehicle color: Silver, Special Usage: Not
applicable. The initial impact point was at 1 o'clock, Damage Indicator: Disabling (severe - not driveable), Vehicle role: Struck, Vehicle position:
in an oncoming traffic lane. Direction of travel: North, Movement: Turning left, Gradient: on a level roadway, Alignment: Straight.
Driver Information:
The driver ofthis unit was CAITLIN 0 SULLIVAN. Address: 1019 N WATERFORD WAY MECHANICS8URG PA 17050. Telephone: 717-732-
6566, Height: 5 Ft 5 In. Drivers License #: 28648779, State: PA. 008: 07/12/1989, Age: 16, Sex: Female. Seating position: driver's seat.
Primary safety equipment: lap and shoulder belt were used. Secondary safety equipment: Front air bag deployed (for this seat). Injury severity:
Minor injury. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: Yes. Alcohol/Drugs Suspected: none suspected, Alcohol Test
Type: Test not given, Alcohol Test Results: Result = 0,00. Driver's action(s), 1 making an improper / careless turn. The individual's condition
was apparently normal. Vehicle code VEHICLE TURNING LEFT (SEC. 3322) was violated, Citation was written.
Passenger Information:
A passenger (1): DONALD SUMPLE, Address: CODY KS. 008: 03/14/1989, Age: 16, Sex: Male. Seating position: Front seat right side.
Primary safety equipment: lap and shoulder belt were used. Secondary safety equipment: Front air bag deployed (for this seat). Injury severity:
Minor injury. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: Yes.
UNIT INFORMATION: 2
http://www.dot6.state.pa.us/crash.nsf/Synopsis?OpenF orm&Seq= 1
4/12/2006
Page 2 of2
Unit Number 2 was a motor vehicle in transport. The unit was owned by SHELLY E ASH. Address: 6 THYME CT, MECHANICSBURG, PA
17050. Travel speed: 040. Unit insured: vehicle has insurance, Insurance Company: ERIE INSURANCE EXCHANGE, Policy number:
Q021903546H. The Unit was towed by ROADSIDE AUTO RESCUE. This was not a commercial vehicle. This Unit was a van, Vehicle color:
Blue, Special Usage: Not applicable. The initial impact point was at 11 o'clock, Damage Indicator: Disabling (severe _ not driveable), Vehicle
role: Striking, Vehicle position: in the left lane. Direction of travel: West, Movement: Going straight, Gradient: on a level roadway, Alignment:
Straight.
Driver Infonnation:
The driver of this unit was SHELLY E ASH. Address: 6 THYME CT MECHANICSBURG PA 17050. Telephone: 717-766-6459, Height: 5 Ft 4
In. Drivers License #: 20723464, State: PA. DOB: 09/17/1963, Age: 42, Sex: Female. Seating position: driver's seat. Primary safety
equipment: None used / Not applicable. Secondary safety equipment: None used / Not applicable. Injury severity: Major injury. Ejection: Not
ejected. Extrication: Extricated by mechanical means. EMS Transport: No Entry Made. AlcohoVDrugs Suspected: none suspected, Alcohol
Test Type: Test not given, Alcohol Test Results: Result = 0.00. Driver's action(s), 1 No contributing action, The individual's condition was
apparently normal.
Passenger Information:
A passenger (1): AMANDA ASH, Address: 6 THYME CT. MECHANICSBURG PA 17050. Telephone: 717-766-6459. DOB: 12/30/1989, Age:
16, Sex: Female. Seating position: Front seat right side. Primary safety equipment: None used / Not applicable. Secondary safety equipment:
None used / Not applicable. Injury severity: Moderate injury. Ejection: Not ejected. Extrication: Not extricated. EMS Transport: Yes.
Passenger Infonnation:
A passenger (2): MICHAEL ASH, Address: 6 THYME CT. MECHANICSBURG PA 17050. Telephone: 717-766-6459. DaB: 01/05/1991, Age:
15, Sex: Male. Seating position: Second row -left side or motorcycle passenger. Primary safety equipment: lap belt was used. Secondary
safety equipment: None used / Not applicable. Injury severity: Minor injury. Ejection: Not ejected. Extrication: Not extricated. EMS Transport:
Yes.
[ Cl~se. w.i.nclow. J
http://www.dot6.state.pa.us/crash.nsf/Synopsis?OpenF orm&Seq= 1
4/1212006
fi. ENCOMPASS.
INSURANCE
P.O. Box 16203, Reading, PA 19612
encompassinsurance.com
Marty Davis
Claims Specialist
Telephone
(610) 401-2252
(800) 936-4203 x12252
(972) 510-1382
marty.davis@encompassins,com
January 10, 2007
Facsimile
Internet
ANGINO & ROVNER, P.C.
A TIN: RICHARD A. SADLOCK
4503 NORTH FRONT STREET
HARRISBURG PA 17110-1708
Our Claim Number: Z0024677 EE
Your Client: Amanda Ash
Your Reference Number: Amanda Ash v Sullivan
Our Insured: Daniel L & Barbara Sullivan
Date of Loss: 03/09/2006
Policy Number. US 211146139
Insuring Company: Encompass Insurance Company of America
Dear Attorney Sad lock:
This will confirm that we have agreed on the settlement of Amanda's claim for $120,000 pending
approval of the minor's compromise
In order to complete the settlement I will need the following:
a) The signed and notarized release signed by both Mr. and Mrs. Ash.
b) Copy of the court approval of the Minor's Compromise.
c) Letter from lien holder advising that agreement was reached with you on the disbursement
of the lien and authorizing us to issue payment.
Once this information has been received, I will promptly issue the settlement draft.
Please feel free to contact me if you have any additional questions.
Sincerely,
:Marty (]Jaw
Encl: General Release
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Angino & Rovner, P.C.
** CASE/ACCOUNTING REGISTER ....
PREPARED: 1/12/2007
FILE NUMBER.. ....... ...: 06061
CLIENT.. ......... ......: ASH, SHELLY, AMANDA, MICHAEL
----------------------------------------------------------------------------------------------------
DIGITAL PHOTO C.D. 'S
11/01/2006
6.00
EXPENSE TYPE TOTAL: INVESTIGATION EXPENSE
12.00 ..
MILEAGE
MILEAGE
MILEAGE
MILEAGE
3/31/2006
4/10/2006
4/10/2006
10/31/2006
23.59
28.93
16.47
12.91
EXPENSE TYPE TOTAL: MILEAGE
81,90 ..
COLOR COPIES
COLOR COPIES
COLOR COPIES
3/31/2006
4/11/2006
11/01/2006
48.00
36.00
36.00
.50
.50
.50
24.00
18.00
18.00
EXPENSE TYPE TOTAL: PHOTOCOPIES
60.00 ..
POSTAGE
POSTAGE
5/10/2006
11/29/2006
.39
.39
.78
2.00
EXPENSE TYPE TOTAL: POSTAGE
1.17 ..
SUB-TOTAL
554.09 **
----------------------------------------------------------------------------------------------------
...... CHECK EXPENSES ......
DESCRIPTION DATE CHECK# AMOUNT
HAMPDEN TOWNSHIP POLICE DEPT. 4/27/2006 910894 25.00
SOURCECORP HEALTHSERVE, INC. 5/03/2006 68464 45.17 I
HERSHEY MEDICAL CENTER 5/10/2006 68492 15.00
HERSHEY MEDICAL CENTER 5/10/2006 68492 15.00
SOURCECORP HEALTHSERVE, INC. 5/~ 86.38
SOURCECORP HEALTHSERVE, INC. 5/31/2006 68721 183.88
SOURCECORP HEALTHSERVE, INC. 7/20/2006 69213 26.31
EVERETI' C. HILLS, M.D. 7/26/2006 69270 562.50
SOURCECORP HEALTHSERVE, INC. 9/20/2006 69811 235.15
~ILLO- 10/11/2006 70022 10.00
-
SOURCECORP HEALTHSERVE, INC. 11/21/2006 70467 58.53
INTREPID USA HEALTHCARE SVCS. 11/29/2006 70533 76.15
WILLIAM A. CANTORE, M.D. 1/10/2007 70882 750.00
LO.D., INC. 1/10/2007 70885 30.66
-==-=----===-
SUB-TOTAL 2,222.57 ....
-------..---
TOTAL EXPENSES 2,776.66 ......
----------------------------------------------------------------------------------------------------
.......... RECEIPTS
*****
SOURCE
REASON
DATE
AMOUNT
PAGE:
2
loJ..8L/
55. 50 (if
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U./UO'L~~r ~C;~C
l:l'lfl:l.::s'jfLt:Jq
~~~ ~~~UV~~y ~~~V~~~
t"'1-l1.:3~ t1~ftl~
AC& Recovery SerVI'CeS
formerly Primax Recoveries Incorporated
P.O. Box 4003, Schaumburg, IL 60168.4003
January 8, 2007
Mr. Richard Sadlock
Angino & Rovner, P.C.
4503 North Front Street
Harrisburg, PA 17110
Claimant:
Our Case ID:
Date of Loss:
Our Client:
Michael AshlAmanda Ash
7517602
03/09/2006
HealthAmerica and HealthAssurance
Dear Mr. Sedlock:
This is to confirm our agreement of 01/08/2007 regarding settlement of our claim and lien
concerning the above matter for the total sum of $ 17,791,30. It is my understanding that
you will forward a check payable to ACS Recovery Services (tax ID # 36-4129784) in the
amount of $ 17,791.30 within thirty days.
It is also our understanding that this agreement is contractual, not a mere recital. and is
intended to represent a full and final settlement of the claims of the parties. In consideration
of this agreement, ACS Recovery Services waives and releases any claim for retmbursement
for medical expenses advanced on behalf of your client for injuries arising out of the loss
described above. In consideration of this agreement, you. on behalf of your client, hereby
waive and release any claim against ACS Recovery Services arising out of its claim of lien for
reimbursement of medical expenses arising out of the loss described above, whether at law or
at equity.
If this is not your understanding, please contact the undersigned as soon as possible so that
we may clarify this matter.
Very truly yours,
~~
Natalie Bryk
ACS Recovery Services
(847) 839-7254
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VERIFICATION
We, Rodney and Shelly Ash, as parents and natural guardians of Amanda Ash, have read
the foregoing PETITION FOR APPROVAL OF MINOR PLAINTIFF'S COMPROMISE
SETTLEMENT AND DISTRIBUTION OF PROCEEDS and do hereby swear or affirm that the
facts set forth in the foregoing are true and correct to the best of our knowledge, information and
belief. We understand that this Verification is made subject to the penalties of 18 Pa.C.S.A. Section
4904, relating to unsworn falsification to authorities.
Witness
((4~~
Rodney Ash
~
Dated: / / I (j() 7
345791
,
.
CERTIFICATE OF SERVICE
I, Marcy L. Brymesser, an employee of Angino & Rovner, P.C., hereby certiJ} that a true
and correct COpy of the foregoing PETITION FOR APPROVAL was served via United Slales
first-class mail, postage prepaid, upon the fonowing:
Mr. Marty Davis
Claims Specialist
Encompass Insurance
P.O. Box 16203
Reading, P A 19612
Date: January 15,2007
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JAM 19 2007 ,(
ANGINO & ROVNER, P.e.
Richard A. Sadlock, Esquire
Attorney ID#: 47281
4503 North Front Street
Harrisburg, PA 17110-1708
(717) 238-6791
FAX (717) 238-5610
E-mail: rsadlock@angino-rovner.com
Attorneys for Plaintiffs:
Brian Speck and Rachel Soeck
RODNEY AND SHELLY ASH, As
Parents and Natural Guardians of
AMANDA ASH, a minor,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
AMICABLE ACTION
v.
CAITLIN SULLIV AN
Defendants
NO. 0'1- 3,J.S
C,~,'l'--r~.
ORDER
AND NOW this
z o/~ day of
1a.-v~
, 2007, upon
consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered that the
Petitioners are authorized to enter into a settlement of One Twenty Thousand Dollars
($120,000.00). Petitioners are authorized to sign a Release.
The settlement amount shall be distributed as follows:
TO: Angino & Rovner, P.C. , attorneys at law, $30,000.00 for counsel fees;
TO: Angino & Rovner, P.C. , attorneys at law, $158.34 for reimbursement of costs;
TO: ACS Recovery Services, $17,791.30 for reimbursement of the
HealthAmericalHealthAssurance lien;
~~
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68 :8 [.JJ f12 NVr LOOZ
AbV10i\D,U.UUd 3Hl.:lO
3:Jl:!:'(}-CBll.:!
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.
TO: Rodney and Shelly Ash, as Parents and Natural Guardians of Amanda Ash, a
minor, $72,050.36 to be deposited into a restricted, federally insured account
marked "No withdrawals prior to age 18 without prior court approval."
TOTAL AMOUNT OF DISTRIBUTION:
$120,000.00
Counsel shall provide to the Court, within ten (10) days from the date of this order proof
of such deposit.
BY THE COURT: I
~ ;1~
J.
....
ANGINO & ROVNER, P.c.
Richard A. Sadlock, Esquire
Attorney 10#: 47281
4503 North Front Street
Harrisburg, P A 1711 0-1708
Phone (717) 238-6791
Fax (717) 238-5610
E-mail: rsadlock@angino-royner.com
Attorneys for Plaintiffs:
Rodney and Shelly Ash for Amanda Ash. a minor
RODNEY AND SHELLY ASH, As
Parents and Natural Guardians of
AMANDA ASH, a minor,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
AMICABLE ACTION
v.
CAITLIN SULLIV AN,
Defendant
NO. 07-325 (Civil)
PROOF OF DEPOSIT OF MINOR'S FUNDS
In accordance with Pennsylvania Rule of Civil Procedure 2039, counsel for Plaintiffs,
hereby certifies that the net settlement amount of $72,070.10, as set forth in the Court's Order
dated January 24,2007, was deposited by Rodney and Shelly Ash, parents and natural guardians
of Amanda E. Ash, a minor, in an account at Wachovia Bank. No withdrawal can be made from
any such account until the Minor attains majority, except as authorized by a prior Order of Court.
The Proof of Deposit is attached hereto as Exhibit A.
Date: March 6, 2007
t'
W"ACHOVIA
TIME DEPOSIT
AUTOMATICALLY RENEWABLE
PERSONAL CD 24 MONTH STEP RATE
Opening Date
Account Number
Taxpayer ID Number
MARCH 05, 2007
247402302921143
194521104
This Receipt Acknowledges That The Depositor Named
Below Has Deposited With This Bank The Sum Of $ *********72,070.10*****
Depositor
Name And
Address
RODNEY A ASH
SHELLY E ASH
AMANDA E ASH
6 THYME CT
MECHANICSBURG PA 17050
Term
Maturity Date
MARCH 05, 2009
Interest Rate Per Annum
04.16%
Annual Percentage Yield Interest Payment Frequency/Period
24 MONTHS
04.25%
1 MONTH[S]
Interest Payment Disposition
CAPITALIZE
Account to Credit
PROD-TYPE: 230
PROMO CD:
Issued by WACHOVIA BANK, NA
NE CNTRL PA / MECHANICSBURG
PA
x 8/sh
Date /
Member FDIC
NOT
566591 (Rev 04 Page 1 of 3)
CUSTOMER RECEIPT
,/ II . to
CERTIFICATE OF SERVICE
I, Marcy L. Brymesser, an employee of Angino & Rovner, P.C., hereby certify that a true
and correct copy of the foregoing PROOF OF DEPOSIT was served via United States fIrst-class
mail, postage prepaid, upon the following:
Ms. Karen Irey
Claims Specialist
Enconnpasslnsurance
P.O. Box 16203
Reading, P A 19612
Date: March 6, 2007
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