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Home My WebLink About02-4528THIS IS AN ARBITRATION CASE MORRIS &ADELMAN, P.C. ~NOTR~UIR~ BY: JAMES W. ADELMAN, ESQUIRE ATTORNEY FOR PLAINTIFF IDENTIFICATION #02604 P.O. BOX 30477 Atlantic States Insurance Cos. Philadelphia, Pennsylvania 19103-8477 '(215) 568-5621 Atlantic States Insurance Cos. '1195 River Road Marietta PA 17547 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION vs. : Rillo's Inc. : 50 Pine St : Carlisle PA 17013 : NO. (~a -/~ COMPLAINT CIVIL ACTION NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE TH E OFFICE BET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELR Name Address City CUMBEI~I.ARD COUN'J:Y BAR ASSOCIATION 2 LIB]~I~ AVENUE CAELISLE, PA 17013 Tel. No. (717) 249-3166 1. Plaintiff is Atlantic States Insurance Cos., an insurance company duly authorized to issue insurance policies in the Commonwealth of Pennsylvania. 2. Defendant is Rillo's Inc. 3. Plaintiff, at the request of Defendant, or Defendant's authorized agent, issued a Worker's Compensation and Employer's Liability policy naming Defendant as the insured. A true and correct copy of the policy is attached hereto, incorporated herein and marked Exhibit "A". rules, rates and -Compensation Bureau premium is subject 4. The total annual estimated earned premium for the insurance year set out in the policy was $7,671.00. In accordance with the classifications of the Pennsylvania Worker's (PWCB) and the premium endorsement, the estimated to increase or decrease in accordance with the actual payroll figures established by the insured but not available at time of policy issuance. 5. Plaintiff was pezmitted to audit the true and correct books and records of the Defendant. v.e~la~CATION Daniel J. Wagner, CPA Vice President & Treasurer and that the facts set forth in the foregoing COMPLA~NT , states that he is of Atlantic States Insurance ComDanv are true and correct to the best of his k-nowledqe, information and belief, and that this statement is made subject to the penalties of 18 Pa. C.S.A. 4904 relating to u~sworn falsification to authorities. Dated: August 29, 2002 Daniel J. Wggner,C~ 'ACORD~ COMMERCIAL INSURANCE APPLICATION -- APPLICANT INFORMATION SECTION PRODUCER [ ~HcO,~o, ~,1: ( 7 Z 7) 241~ 599 ~ NAIC COOS: FAX (717)241-6366 Donegal Mutual /nsurance .Hopcraft, Hockley & 0'Donne]] Ins Agency ~, PA 17325 AGENCY CUSTOMER iD 0000606S STATUS O~ SUBMISSION APPLICANT INFORMATION DATE 02/15/2000 INDICATE SECllONB AI'i'ACHED I J EQUIPMENT FLOATER PROPERTY ~ INSTALLATION~IUJLDERS RISK GLASS AND SIGN ELECTRONIC DATA PROC ACCOUNTS RECEIVABLE/ COMMERCIAL VALUABLE PAPERS GENERAL LIABILITY CRIME/MISCELLANEOUS CRIME BUSINESS AUTO TRANSPORTATION/ MOTOR TRUCK CARGO TRUCKERS/MOTOR CARRIER POLICY INFORMATION ENTER THIS INFORMATION WHEN C OMM(~N DATES AND TERMS APPLY TO SEVERAL LINES. OR FOR MONOLINE POLICIES. JiOIKEDTS'L Zl, /, Zl, l, / AGENDYS,LL INDIVIDUAL ~ CORPORATION ~ SUBCH~PTER'~"CGRPORAT,ON PARTNERSHIP ) ) JOINT VENllJRE t I LIMITED CORPOP~TION PH NE iGARAGE AND DEN.ERS VEHICLE SCHEDULE BOILER & MACHINERY WORKERS COMPENSATION ._~ UMBRELLA PREMISES INFORMATION SO Pine Street Carlisle, PA 17013 ~ m l N°T FOR PROFITORGANIZATION BUBI~sI~'ARTE D IACCOUNTING RECORDS CONTACT I (~,%. ~'): LOC# BLD# 50 PINE ST~TREBT' CITY, COUNTY. STATE, ZIP+4 00001 00001 / / PA 17013 PA 17013 NATURE OPBUSINESSIDESCRIPTION OF OPERATIONS RESTAURANT URANT GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES 1. ISTHEAPPL[CANTASUSSI IARYOFAN THER ENTiTY OR DOES THE APPLICANT HAVE ANY ~USS OIARIE ~)J 2 IS A FORMAL SAFETY PROGRAM IN OPERATION? 3 ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? 4 ANY CAI'ASTROPHE EXPOSURE? 5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITFED? S. DA~RYI~NgLTICH~ O~ ~ i Co O~ 5~yR~REs ~D ~N%~AE~D~ 5gANaCLE~L ~ ~ 8R NON-R~[NEWeD REMARKS YES NO I EXPLAIN ALL 'YES' RESPONSES x MOLES~2T,ON A.LEGA~b%, D,~M~NAT,ON O~ NEQU~NT 7 ANYPA TLOSSESOR IMSR TINGTOSEX ALASU OR ~ ~X)an--'" bY ~Y e~pli~nt for .o.~ ins~ Failure to ~se lyES NO ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ~,N,~Y ,F_A~C..T_ M_A.T_E_R_IA_L_ _T.H.E_R_ETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND u~a:~./~/tii: H~(JN TO CRIMINAL AND [NY: SUBSTANTIAL] CIV L PENA~ (8197~ ' PLEASE OOMPLETEREVERSESIDE -' Jk~'~'~'D~Cj~ R p ORA T,O N 19 9 3 FAX (717)241-6366 ~opcraft, Hockley & O'Donnell Ins Agency P. O, Box 116 1 Valley Street, Suite 101 Settysburg, PA 17325 CODE: AGENCYC 00006065 SUBCODE: COMPANY UNDERWRITER Donegal Mutual Insurance APPLICANT NAME MAILING ADDRESS 50 Pine Street ~JP¢o~.~ Carlisle, PA 17013 Cumberland YRS IN BUS SIC ~l INDIVIDUAL [__.,X I-C O~P 0 RA~OIO; [ ~ OTHER: PARTNERSHIP I I SUBCHAPTER "S" CORP FEDERAL EMPLOYER ID NUMBER NCCl iD NUMBER TOTHER RATING BUREAU D NUMBER -- QUOTE I ISSUE POLICY i BILLING PLAN ~, PAYMENTPLAN BOUNO(GivsdaleanU/oraltachcopy) 02/11/2000 AGENCYBILL --ANNUAL OTHER: i ! AT~XPIRATION MONTHLY ASSIGNED RISK(Attach ACORD 133) DIRECTEILL I i SEMI-ANNUAL ~ ~----1[ SEMI*ANNUAL OTHER: QUARTERLY i % DOWN: ! J QUARTERLY STREET, CITY, COUNTY, STATE, ZIP CODE 00002 $0 PTNE ST. CARLISLE, PA 17013 PROPOSED EFF DATE (MM/DD/YY) PART 1 CJMPENEAT1ON (States) PART 2 - EMPLOYER'S LIABILITY PA $ 100,000 EACH ACCIDENT $ S00,000 DISEASE-POLICY LIMIT $ 100,000 DISEASE-EACH EMPLOYEE DiVl b-E-N5 PL'Ei~/SA~i=~'~A6 OF ...... l ADDITIONAL COMPANY INFORMATION MEDICAL INDEMNITY COM- STATE i LOC i C 'bASS CODE i PANY CATEGORIES, DUTIES, CLASSIFICATiONS I I USE .... -]-- .... --~----- RESTAURANT Z~'Z~ CX:)O #OF IPLOYEES! ~ ~2.4900 ESTIMATED ANNUAL PREMIUM [. FACTOR FACTORED PREMIUM INCREASED LIMITS $ EXPERIENCE MODIFICATION ; · · 9 S ~ MINIMUM PREMIUM $ 38~ i 00' 6E~omr P~'U~ $ ' 6,801 · 00 TO'rAL EST ANNUAL PREMIUM ~ ;3 ....~,~-1~-.~0 PARTNERS, OFF)CERS. RELA33VES TO BE INCLUDED OR EXCLUDED, (Remuneration o be included must be par1 of rating in onna on sec on .~ 2~ONS_~ ~ .S~HIp % DUTIES INCIEXC CLASS CODE REMUNERATION ................. ~- .... CLAIMS AMOUNT PAID RESERVE EXPLAIN ALL 'YES' RESPONSES 1. DOES APPLICANT OWN, OPERATE OR LEASE AIRC R^ F~'/WATER C RAFT? , DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS JNVOLVE(D) STOKING, TREATING, DISCHARGING, APPLYING, DISPOSING. OR TRANSPORTING OF HAZARDOUS MATER AL? (e g. andfl s, wastes, fuel ~anks, etc) 3. ANY WORK PERFORMED UNDERGROUND OR AEOVE 15 FEET? 4 ANY W~RK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER? 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF EiUSINESS? 6. ARE SUB-CONTRACTORS USED? 7. ANY WORK SUBLET W~TNOUT CERTIFICATES OF INS.? 8 IS A FORMAL SAFETY PROGRAM IN OPERATION? EXPLAIN ALL "YES" RESPONSES X 15. ARE ATHLETIC TEAMS SPONSORED? 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? CONTACTINFORMA~ON 10. ANY EMP~ ")YEES UNDER 16 OR OVER 60 YEARS OF AGE'~ j X I SPEC31ON NAME 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? ...... J [ ~ RECORD NAME APPUCANT*S SIGNATURE PRODUCER'S SIGNATURE STATEMENT OF ACCOUNT October 22, 2001 Rillo's, inc. 50 Pine Street Carlisle, PA 17013 Policy No.: WCA 0025920-00 02/11/00.to 02/11/01 Deposit Premium Audit, 03/01 Audit Revision, 06/01 Total Due: Payments 7,671.00 3,479.00 8~.00 [ 12,045.00] (1,911.50) (1,151.90) (1,151.90) (1,151.90) (1,151.90) (1,151.9~) 04/14/00 05/12/00 06/08/00 08/16/00 10/18/00 12/11/00 Total Paid GRAND TOTAL DUE ATLANTIC STATES [ (7,671.00~ L 4,374.00j HOME OFFICE COPY 06/27 -DB * A UD I T INFORMATION PAGE* 0025920 00 RILLO'S INC 50 PINE ST CARLISLk PA EFFECTIVE 02/11/00 12:01 AM o2/ii/oi ATLANTIC STATES INS. CO. 000431300 17013 HOPCRAFT HOCKLEY & O'DONNELL INSURANCE AGENCY P 0 BOX 116 CARLISLE PA 017013 TELEPHONE 717/241-5995 04 NO. BASIS PREMIUM ~/ii/00 TO 07/23/00 ~STAURANT [PERIENCE MOD. ;HEDULE MOD. CREDIT '/23/00 TO 02/ii/0i :STAURANT [PERIENCE MOD. ;HEDULE MOD. CREDIT {PLOYER ASSESSMENT 975 9898 9887 975 9898 9887 $198,901. $402,148. 0938 EXPERIENCE RATING MODIFICATION FACTOR. (9898) PREMIUM DISCOUNT (0063) LOSS CONSTANT (0032) EXPENSE CONSTANT (0900) OTHER. 2.76 .951 25% 2.92 .961 25% .0375 $ 5,490.00 - 269.00 -1,305.00 11,743.00 - 458.00 -2,821.00 304.00 - 804.00 140.00 EARNED PREMIUM I $i2,020.00 ~ LESS DEPOSIT PREMIUM I $ 7,646.00 TOTAL BALANCE DUE: COMPANY $ 4,374.00 ADDITIONAL PREMIUMS DUE COMPANY ARE PAYABLE UPON RECEIPT OF THIS PREMIUM [USTMENT ENDORSEMENT. RETURN PREMIUMS DUE INSURED ARE PAYABLE PROVIDED THE ESTIMATED DEPOSIT ]MI UMS ARE PAID IN FULL. JLB DONEGAL COMPANIES FEDERAL ID. ~-.~-~ ~v~ AUDIT SUMMARY BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code Policy Number Policy Name Company Name / %~....~.~ Contact's Name Street Address c~ AJH state Policy Date Reporting Date Auditor Completion Date WCA 0025920 00L3 WORKERS COMP ATLANTIC Rillos Inc Joe Rillo 50 Pine St Carlisle PA 17013 02111/2000 To 02/1112001 02/11/2000 To 07/23/2000 Joe Gilmartin 0211512001 L 02/11100 ~ 07123100 T~T L# STATE LOCATION CODE CLASS AL ADJUSTED PREVIOUS DELTA ~~1101 TOTAL BASIS 1 PA Carlisle ~estaurant 198,901 60%049.00 487,368.00 400,000 21.84' SPLIT 1 TOTAL SPLIT 2 TOTAL AUDIT TOTAL ADJUSTED TOTAL TOTAL BASIS TOTAL DELTA [ 1'8"°1'0°11 I oo,o Description of Operations THIS IS A ITALIAN STYLE RESTAURANT SERVING ALCOHOLIC BEVERAGES AND FINE DINING~ BOTH OFFICERS ARE INVOLVED IN THE BUSINESS. THE MOTHER TAKES CARE OF CLEANING THE LINENS PRrMARILY ANOTHER SON IS IN MANAGEMENT BUT IS NOT AN OFFICER IN THE CORPORATION. Home OJ~f ice, 11 PajillDrive, Marietta, Penn~. lvania 17457 (71 7) 426-1904) DONEGAL COMPANIES FEDERAL ID. ~.,., SUMMARY DETAIL BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code 4-0vov~9 ]HI .~00~,0038~ II 4848 I ~ I Po,ioyNumberWCA 0025920 00 Policy Name WORKERS COMP ATLANTIC Company Name Rillos Inc Street Address 50 Pine St city Carlisle State PA Zip '17013 Policy Date 02/11/2000 To 02/11/2001 Reporting Date 02111/2000 To 07~23~2000 Auditor Joe Gilmartin Completion Date 02/1 $/2001 Phone 243-6141 N# L# Code Title Name/Group Total Adjusted Description Function ~ I 975 Restaurant Staff 584,655.00 584,655,00 COOKS, SERVERS, SARTENDE Employee 2 1 975 Restaurant Staff 0,00 (128,487.00) EXCESS TIPS Employee 3 1 975 President Joseph Rffio 2,200.00 6,900.00 RESTAURANT MANAGEMENT Officer 4 1 975 President Joseph Rillo 3,000.00 8,700,00 RESTAURANT MANAGEMENT Of~cer 5 I 975 Secretary Magdstene Rillo 4,721.00 6,900.00 MANAGEMENT CLEANING OF L Officer 6 1 975 Secretary Magdalene Rillo 6,473.00 8,700.0(~ MANAGEMENT CLEANING OF LI Officer Source of Data Verification Was There IINSURED ...,._a [YTD PAYROLL ] I I .J [PAYROLL SPLITS J I Legal Entity Subcontractor Amount Gross Overtime Ic°r"°rat'°' J l $ol I a c s Homer)J.! ~ce, 11 P,4JILL DR[FE,,t4.4ltlETTA..OENNSYLV.4~ViA 17547 (717) 426-1904 Period Totals 0?J11/2000 To 07/23/2000 251,408 07/23/2000 To 02/11/2001 349,605 To To To To TOTAL 601,013 DONEGAL COMPANIES Class Description Summary BATCH NUMBER INFACS CODE INVOICE NUMBER INS Code [ 4-0~;0~;19 ]1EI200~0038511 !648 II 4 I NAME # TITLE NAME/GROUP I Restaurant Staff .olicyNum~,WCA 0025920 00 Policy NameWORKERS COMP ATLA Company NameRiJlos Jrtc Street AddressS0 Pine St CityCarlisle State PA zip17013 Policy Date02/1112000 To 02/11/2001 Reporting Date02/11/2000 To 07~23~2000 Auditor Joe GiJmartin Completion Date02/1512001 DESCRIPTION OF DUTIES COOKS, SERVERS, BARTENDERS, KITCHEN HELP, MANAGERS 2 Restaurant Staff EXCESS TIPS 3 President Joseph Rillo RESTAURANT MANAGEMENT 4 President Joseph Rillo RESTAURANT MANAGEMENT 5 Secretary Magdalene Rillo MANAGEMENT CLEANING OF LINENS 6 Secretary Magdalene Rillo MANAGEMENT CLEANING OF LINENS Sunday, February 18,2001 Home (3f f tc~ 11 PA JILL DRII~'E. MARIETTA, PENNSYL VANL4 17547 (71 7) 426-1904 WCA 0025920 00 02/11/2000 E200100385 Rillos Inc 01/18/2001 Quality Assurance The function of tiffs audit is to assure that your policy has been properly undenYntten from the information we collect through our survey process. Tliere are many occasions in wbich pre~rdtlms may be adjusted to reflect what Donegal Companies may feel is appropriate. If you disagree with thc results of our survey because you may feel it is ioaccurate, you should make your position known to hffacs and tlie underwriters at Donegal Companies ' It is our intention to treat you in the most courteous and respectful manner possible. If you feel that you have not received this level of service, it is important that you contact us so that we may address your displeasure. We value your input and hope that you understand this process helps provide the best possible service and coverage for you and your business as well as our other valued policyholders. Verification To the best of nay knowledge, this survey was conducted witli my understanding and that the information to construct this survey was supplied by me or my representatives, either orally or by documents which pertain to fi'ds survey. I believe my statements and docmnenls offered to the surveyor to be accurate and current and all representations to be truthful. Date Home Off tee, EasternReglon 11 PA,IILL DRII/E, Aq,4R/ETT,4, PEiVNSI'L I'~4NI,4 17547 (717) 426-1904 The Widener Building -6th Floor One South Peon Square · Philadelphia. PA 19107-3577 (215)568-2371 · FAX (215)564-4328 · www.~crb.com ATLANTIC STATES INSURANCE CO Pennsylvania Compensation Rating Bureau 1195 RIVER RD PO BOX 302 MARIETTA PA 17547 RILLO'S INC 06/07/01 RE: FILE NLq~ER M 208706 POL NUM WCAO02592000 POL PER 02/11/00 - o2/11/0i ENDOR. EFF. DATE - 07/23/00 POL. ANNIV. DATE - 07/23/00 THE ABOVE ENDORSEMENT ~AM BEEN DISAPPROVED AS NOTED BELOW. KINDLY MAKE THE NECESSARY CORRECTIONS. DOES NOT ACCORD WITH DATA CARD 000001 EXPERIENCE MODIFICATION INCORRECT .951 SHOULD BE .961 ~/ ANNIVERSARY RATING ACCOUNT - FROM 07/23/00 TO 02/11/01CA/~RIER RATING VALUES IN EFFECT 07/23/00 APPLY. IF AN ERROR IS CITED BELOW, ENDORSE IM/~EDIATELY. HOWEVER, YOU MUST ENDORSE THE SECOND PERIOD WI~ THE CARRIER RATING VALUES AND MOD (LF APPLICAJILE) BECOME AVAILABLE. *INCORRECT RATE 2.63 FOR CLA~S 975 SHOULD BE 2.92 CODE 0938 EMPLOYER ASSESSNENT OMITTED. IMMEDIATE AD4USTHENT REQUIRED. JUL 0 6 ZOO1 VERY TRULY YOURS, POLICY REPORTING EXTENSION 490 093 034 A COPY OF THIS LETTER MUST BE ATTACIIED TO YOUR RESPONSE. SHERIFF'S RETURN - CASE NO: 2002-04528 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND ATLANTIC STATES INSURANCE COS VS RILLO'S INC REGULAR DAWN KELL Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to says, the within COMPLAINT & NOTICE was served upon RILLO'S INC the DEPENDANT at 1429:00 HOURS, at 50 PINE STREET CARLISLE, PA 17013 JAMES ALLEN, MANAGER on the 25th day of September, 2002 by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 3.45 Affidavit .00 Surcharge 10.00 .00 31.45 Sworn and Subscribed to before me this ~ ~-- day of ~a~. o16~ A.D. P~h~6tary ~ So Answers: R. Thomas Kline 09126/2002 Deputy Sheriff MORRIS & ADELMAN, P.C. BY: JAMES W. ADELMAN, ESQUIRE IDENTIFICATION ~02604 P.O. BOX 30477 Philadelphia, Pennsylvania (215) 568-5621 Atlantic States Insurance Cos. 1195 River Road Marietta PA 17547 vs. Rillo's Inc. 50 Pine St Carlisle PA 17013 ATTORNEY FOR PLAINTIFF Atlantic States Insurance Cos. 19103-8477 COURT OF COMMON PLEAS CUMBERLAND COUNTY CIVIL DIVISION NO. 2002-04528 ORDER TO SETTLE, DISCONTINUE & END TO THE PROTHONOTARY: Mark the above-entitled case settled, discontinued and ended upon payment of your costs only. So Ordered As Ab~ t~rneys For Plai/ntiff F: \CLS INC\WORD\JWA1022 - 4