Preview
MC—350
ATTORNEY OR PARTY WITHOUT ATTORNEY
(Name, Slate Barnumber, and address): FOR COURT USE ONLY
Richard Aharonian‘ Esq. (CA State Bar No. 169586)
7108 320
N, Fresno Street, Suite
E-FILED
Fresno, CA 93720 3/6/2019 1:06 PM
TELEPHONE No;(559) 437-6463 FAX No. (559) 431-5720
(Optional).-
ADDRESS
E-MAIL (omionau;
FRESNO COUNTY SUPERIOR COURT
ATTORNEY FOR
(Name):
By: A. Ramos, Deputy
Christian Montie| Martinezand Roberto Montiel
SUPERIOR COURT 0F CALIFORNIA, COUNTY 0F FRESNO
1130 "O" Street
STREET ADDRESS:
1130 "O" Street
MAILING ADDRESS:
my AND ZIP CODEFresno, CA 93724
BRANCH NAME BVF. Sisk Courthouse
CASE NAME: CASE NUMBER.
InRe: Aaron Cattlett Hutsell, a minor
Jr.,
19CECG00860
HEARING DATE:
PETITION To APPROVE: COMPROMISE 0F DISPUTED CLAIM
E
E COMPROMISE 0F PENDING ACTION
DISPOSITION OF PROCEEDS 0F JUDGMENT
4/10/19
Minor E Person With a Disability
DEPT:
501 TIME:
3:30PM
NOTICE TO PETITIONERS:
Except as noted below, you must use thisform to request court approval of (1) the compromise of a disputed claim of a minor,
(2) the compromise of a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a
party, or (3) the disposition of the proceeds ofa judgment for a minor or person with a disabifity. (See Code Civ. Prom,
§ 372; Prob.
Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause
dispenses with a personal appearance The court may require the presence and testimony ofwitnesses, including the attending or
examining physician, and other evidence relating to the merits ofthe claim and the nature and extent ofthe injury, care, treatment,
and hospitalization The court may consider on an expedited basis without a hearing requests for approval of the compromises of
certain claims and actions or the disposition ofthe proceeds of certain judgments
If your claim, action, orjudgment qualifies for
expedited consideration and you want to request you must use form MC—350EX for your request. See Call Rules of Court, rule
it.
7950.5.
1, Petitioner (name): DOHEtta EriCkson
2. ciaimant (name); Aaron Cattlett Hutsell, Jr.
a. Address: 6570 Dee Lyle Circle, Casper, WY 82604
b. Date ofbirth:5/24/2003 c. Age: 15 d, Sex:Male e. Minor :1 Person withadisability
3, Relationship
a. Parent g, E
Petitioner's relationshiptothe claimant (check allapplicab/e boxes):
Otherrelationship (specifyr)
E
E
Guardian ad litem
Guardian
Conservator
E]
D Disabled adult claimantis
(Ifyou checked item 3e or
a petitioner.
3f,
(See instructions for/‘tems 36 and 3fbe/ow.)
Disabled adult claimant's express consent to the requested
relief in
on Attachment 3e or 3f showing
state facts
provided on Attachment 3t
this petition is
that the claimanthas capacity under Probate
Code section 812 to petition or consent to a petition.
Only an adult claimant who has sufficient capacity and who does not
have a conservator of the estate may petition or consent 1‘0 a petition.
See Probate Code section 3613.)
4. Nature of claim The claim ofthe minor or adult person with a disability:
a.
b. D Has not been
Is
filedin an action or proceeding. (Complete items 5—23.)
the subject of a pending action or proceeding thatwill be
Name of court:
compromised without a on the merits ofthe claim.
trial
Case no.: Trial date: (Complete items 5—23.)
Page1of 1D
Auerggginvwmgggg‘ggme PETITION To APPROVE COMPROMISE 0F DISPUTE!) CLAIM Codeovg;ggg{gcceggg-§§aggggg:33:
WW“
Jumcaalooummrcanmrma
“ma“! ‘1 201”
0R PENDING ACTION 0R DISPOSITION 0F PROCEEDS 0F Ca..Ru.esmcm mm“
JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY chl‘i’fii'cliil
(Miscellaneous)
MC—350
CASE NAME: CASE NUMBER:
_ln Re: Aaron minor
Cattlett Hutsell, Jr., a
4.
c. D
Nature of claim
Is
the defendants
The claim of the minor or adult person with a disability:
the subject of a pending action or proceeding that has
named below in amount
the total
been or willbe reduced to a judgment for the claimant against
and costs) of (specify below):
(exclusive of interest
s I
Defendants (names!
E Additional defendants listed on Attachment4.
(Attach a
E Thejudgmentwas filedon
copy of the (proposed) judgment as Attachment 4c and complete items 13-23.)
(date):
5. Incident or accident The incident or accident occurred as follows:
a. Date and time; March 4, 2018, at 2:09am.
b. pgace; Highway 168 inFresno County, California
Q persons involved (names); Aaron Cattlett Hutsell, and Christian Montiel Martinez
6.
D Continued on Attachment
Nature of incident or accident
5.
The and circumstances of the
facts, events, incident or accident are (describe):
Aaron had been
Cattiett Hutsell drivingwestbound on Highway 168. east of Cedar Avenue, and was involved in a
singIe—vehicle accident, A second vehicle, driven
leaving his vehicle disabled with no lights on, just after a curve in the road.
by Michael Dewar, then came around the curve and collided with Mr. Hutsell’s disabled vehicle.
Following that collision,
another vehicle. driven by Christian Montiel Martinez,
came around the curve inthe highway and collided with Mr.Hutsell's
vehicle. Mr.Hutsell sustained fatal injuries
as a result.
Itisunknown which specific collisioncaused the fatal injuries.
E Continued on Attachment 6.
7. Injuries
The were sustained by the claimant as a
following injuries result of the incident or accident (describe):
were sustained by decedent Aaron Hutsell, who is survived by two minor
Fatal injuries children -
Aaron Cattlett Hutsell, Jr.,
and Natasha whom are making wrongful death claims.
Hutsell, both of
E] Continued on Attachment
E
7.
8. Treatment
The claimant received the following careand treatment for the injuries
described initem 7 (describe):
E] Continued on Attachment 8.
M0350lReV'JanuaW 1-20“!
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ”992m“
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
4n Re: Aaron Cattlett Hutsell,
Jr.,a minor
9. E Extent of injuries and recovery
and a
for the claimant’s injuries,
(An original or a photocopy of all doctors' reports containing a diagnosis of and prognosis
must be attached
report of the claimant’s present condition, as Attachment
to this petition 9.
A new repon‘ is not necessary so long as a previous
a. E The claimant has recovered completely from
report accurately describes the claimant's current condition.)
the effects of the injuries described
initem 7,and there are no
b_ E permanent injuries,
The claimant has not recovered completely from the effects of the injuries described
from which the claimant has not recovered are temporary (describe the remaining
in item7,
injuries):
and the followinginjuries
E] Continued on Attachment 9b.
0. E: The claimant has not recovered completely from the effects of the injuries described in item 7, and the
following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries):
E: Continued on Attachment 90.
10. Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or
accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Petitioner fully understands that if the compromise proposed in this
petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further
recovery of compensation from the settling defendants named below even though the claimant's injuries may in
the future appear to be more serious than they are now thought to be.
11. Amount and terms of settlement
By way of settlement, the defendants named below have offered to pay the
followingsums to the claimant:
a. The total amount offered by all defendants named below is (specify): 5“2.50000
b. The defendants and amounts offered by each are as foliows (specify):
Defendants (namesz Amounts
Christian Montiel Martinez (vehicle driver)
and Roberto Montie! (vehicle owner)
$ 12,500.00
$
$
$
E
C.
Defendants and amounts offered continued on Attachment
The terms of settlement are as follows
11.
$
(if be paid in
the settlementis to amount and
installments, both the total the
present value of the settlement must be included):
Christian Montiel Martinezand Roberto Montiel have automobile insurance with CSAA Insurance, with a bodily injury
CSAA
policy limit of $25,000. Insurance and the Montiels have offered to resolve the wrongful death claims oanron
Hutsell, and Natasha
Jr., Hutsell for the policy with the $25,000 to be
limit, equafly between the two
split $12,500
heirs, at
each,
D Continued on Attachment 11.
MC'350IReV-January1'2011l PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM PageSoHo
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
—~ln Re: Aaron Cattlett HutseH,
Jr.,a minor
12. Settlement payments to others
a. D No defendant named
settle
initem 11b has offered to pay
same
claims arising out of the
money toany person or persons other than the claimant
incident or accident that resulted
inthe claimant's injury.
to
b. By way of settlement,one or more defendants named initem 11b have also offered to paymoney to aperson or
persons other than claimant to same
settle claims arising out of the incident or accident that resulted
in the
claimant's injury.
_
The amount 121500-00
(1)
(2)
total
Petitioner
reimbursement
is
for
not E
offered byalldefendants to others (speciM:
is
$
a claimant against the recovery of the claimant (other than for
expenses paid by petitioner and listed under item 15)‘
"
(lfyou answered "is, explain in Attachment 12 the circumstances and theeffectyour claim has on the
(3)
proposed com
Petitioner
(If
[fl is
you answered ”is,
not
"
E
romise of the claim described in this petition.)
is a same
plaintiffin the action with the claimant.
explain in Attachment 12 the circumstances and the effect your Claim and its
disposition
(4) E
has on the proposed compromise of the claim or action described in this petition.)
Petitionerwould receive money under the proposed settlement.
(5) The settlement payments are tobe apportioned and distributed asfollows:
Other plaintiffs or
claimants (names) Amounts
Natasha Hutsell (a minor) 12,500.00
$
$
$
E $
:
and amounts are
Additional plaintiffs or claimants listedon Attachment 12.
(6) Reasons for the apportionment of the settlement payments between the claimant and each other
or claimant named above are specified on Attachment 12.
plaintiff
E
13. The claimant's medical expenses, including medical expenses paid by petitionerand insurers, tobe reimbursed from
proceeds of settlement orjudgment
a. Totals
(1) Totalmedicalexpenses: $ 0
(2) Total outstanding medical expenses tobe paid from the proceeds: $
(3) Total out—of-pocket, coapayments, or deductibte
payments to be reimbursed from proceeds: $ I
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
E] Paid by petitionerinthe amountof:
(1)
(2) E Paid by private health insurance or a self—funded plan under:
$
(a) D
D An Employee Retirement Income
An ERISA seIf—funded plan.
Security Act (ERISA) insured plan.
(b)
(c)
(d)
E
D A Non-ERISAinsured plan.
A Non—ERISA seIf-funded plan.
E
(
e) Amount paid by plan: $
Amount of reimbursement to the plan from proceeds of settlement orjudgment:
( f)
(i) E
D No reimbursement
Reimbursement
is requested by the plan.
be made
(ii)
(A) E
E There
isto
is
to the plan and:
a contractual reduction of $
( )
(B)
(C)
a
E There
No
isa negotiated reduction of
reduction has been agreed
reimbursement
to,
$ (
)
for total amount
to the plan in the of: $
MC-350IR6V- January 1'20“}
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page4°f1°
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
~+n Re: Aaron Cattlett Hutsell,
Jr.,a minor
13. The claimant's medical expenses, including medical expenses paid by petitionerand insurers, to be reimbursed from
proceeds of settlement orjudgment
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
3) [:3 Paid by Medicare inthe amount of: $
less the statutory reduction
reimbursement
for a total
(Attach a copy of the
to
in theamount
Medicare in
of:
the
$ (
amount of:
)
Medicare demand letter or letter agreement as Attachment
$ [:::
D Paid by Medi-Cal in
final
theamount of $
13b(3).)
E
)
Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
a)
and Code
Institutions section 14124. 73.A copy ofthe notice and proof of delivery
its D isattached
(b) E [:1 was matter on (date).
filed In this
Notice ofthis claim or action has not been given to the State Director of Health Care Services
(C) E (Explain
inthe
why notice has
amount of:
of
In full satisfaction
not been given
its lien rights,
inAttachment 13b(4).)
Medi-Cal has agreed to accept reimbursement
$
(Attach a copy of the final Medi—Caldemand letter or letter agreement as Attachment13b(4),)
E
E] Petitioneris ofthe Medi—Cal
entitled to a reduction lienunder Welfare and Code
Institutions
(ii)
E
section
E
14124.76 and:
lsfiling amotion seeking a reduction ofthe
Requests that the court reserve
lien
over
jurisdiction
concurrently with this petition.
this issue.
The amount ofthe lien indisputeis:$
There are one or more statutory or contractual medical service providers for payment of medical
liens of
expenses. The amount claimed under these
total liensis: $ , In full satisfaction
oftheir lien claims. the lienholders have agreed to accept the total
sum of: $
(Provide requested information on each lienho/der
and certain other medical service providers below‘)
The name ofeach medical service provider and treatment to claimant and (1) has a lien for all
that furnished care
or any part of the charges or
(2) was paid (or be paid from the proceeds) by petitioner for which petitioner
will
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if
any;
and the amount to be paid from the proceeds ofthe setttement orjudgment to each provider are as follows:
(i)(A) Provider(name):
(B) Address:
(E)
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): $ ( )
(E) Negotiated reduction ifany:
(F) Amount to be paid from proceeds of settlement orjudgment. $
(A)
(ii) Provider(name):
(B) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): $ ( )
(E) Negotiated reduction,ifany: $ (
Amount to be paid from proceeds of settlement orjudgment: $
E (F)
Continued on Attachment 13b(5). (Provide information about additional providers
including providers paid or to be paid
above format,
I'n the
by petitioner for which reimbursement is requested in item 13b(1)
above. You may use form MC—350(A—13b(5)) for thispurpose.)
Mc-sso [Rem January
2011]
1,
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ”995““
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
—~lnRe: Aaron a minor
Cattlett Hutsell, Jr.,
14‘ The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement orjudgment
a. Totalamount which court approval
of attorney's fees for isrequested: $
fees are requested,
(If attach as Attachment 14a,a declaration from the attorney explaining the basis for the request, including
a discussion of applicable factors listed in rule 7.955(b) of the Cal, Rules of Court. Respond to item
18a(2) on page 7 and
attach a copy 0f any written attorney fee
agreement as Attachment 18a.)
b. The
from the incident
m MW $
$
M
expense (other than medical expenses) have been incurred or paid, are reasonable,
following additional items of resulted
or accident, and shouid be paid out of claimant‘s share of the proceeds of the settlement orjudgment:
$
$
$
D
$
$
$
$
$
$
E] Continued on Attachment 14b. Total: $
Reimbursement of expenses paid by
E
15. petitioner
a.
b. E has paid none ofthe claimant's expenses
Petitioner
has paid
Petitioner
reimbursement
(orbecome
items 13 and 14 for which reimbursement
listed in
obligated to pay) the following total
amounts of the claimant'sexpenses
isrequested.
forwhich
(1)
(2)
E
D
is requested.
Medical expenses listed in item
Attorney's fees includedin
13:
amount shown in
the total fee item 14a:
$
$
(3) E: Other expenses included in shown in item
the total 14b: $
(Attach proofs of the expenses incurred and payments made or obligations to pay incurred, orinvoices,
9.9., bills
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
16. Net balance of proceeds for the claimant
The balance of theproceeds of the proposed settlement orjudgment remaining for the claimant
afterpayment of requested fees and expenses is:
all
$ [12,500.00
17. Summary
a. Gross amount of proceeds of settlement orjudgment for claimant:
$ 12,500.00
b. Medical expenses to be paid from proceeds of settlement
orjudgment: $
c. Attorney‘s fees to be paid from proceeds of settlement or
judgment: $
d. Expenses (other than medical)to be paid from proceeds
of settlement orjudgment: $
e. Total offees and expenses tobe paid from proceeds of settlement orjudgment
f.
(add (b),(o),and ((1)):
Balance of proceeds of settlement or judgment available payment
for claimant after of all
$(0__m_)
fees and expenses (subtract (e) from (a)):
$ 12,500.00
MC‘35OIREV-Janua’y1v2m”
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ”96W”
OR PENDING ACTION OR DISPOSITION 0F PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER:
—1n Re: Aaron Cattlett Hutsell, Jr., a minor
18. Information about attorney representing or assisting petitioner
aA (1) [:j has not been represented or assisted by an attorney
Petitioner in preparing this petition or
in any other way with
(Go to item 19.)
respect to the claim asserted.
has been represented or assisted by an attorney in preparing this petition orwith respect to the claim
(2) Petitioner
asserted. and the attorney
Petitioner
connection with the claim giving
do not E
rise to this petition.
Preview
MC—350 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, Slate Barnumber, and address): FOR COURT USE ONLY Richard Aharonian‘ Esq. (CA State Bar No. 169586) 7108 320 N, Fresno Street, Suite E-FILED Fresno, CA 93720 3/6/2019 1:06 PM TELEPHONE No;(559) 437-6463 FAX No. (559) 431-5720 (Optional).- ADDRESS E-MAIL (omionau; FRESNO COUNTY SUPERIOR COURT ATTORNEY FOR (Name): By: A. Ramos, Deputy Christian Montie| Martinezand Roberto Montiel SUPERIOR COURT 0F CALIFORNIA, COUNTY 0F FRESNO 1130 "O" Street STREET ADDRESS: 1130 "O" Street MAILING ADDRESS: my AND ZIP CODEFresno, CA 93724 BRANCH NAME BVF. Sisk Courthouse CASE NAME: CASE NUMBER. InRe: Aaron Cattlett Hutsell, a minor Jr., 19CECG00860 HEARING DATE: PETITION To APPROVE: COMPROMISE 0F DISPUTED CLAIM E E COMPROMISE 0F PENDING ACTION DISPOSITION OF PROCEEDS 0F JUDGMENT 4/10/19 Minor E Person With a Disability DEPT: 501 TIME: 3:30PM NOTICE TO PETITIONERS: Except as noted below, you must use thisform to request court approval of (1) the compromise of a disputed claim of a minor, (2) the compromise of a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a party, or (3) the disposition of the proceeds ofa judgment for a minor or person with a disabifity. (See Code Civ. Prom, § 372; Prob. Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause dispenses with a personal appearance The court may require the presence and testimony ofwitnesses, including the attending or examining physician, and other evidence relating to the merits ofthe claim and the nature and extent ofthe injury, care, treatment, and hospitalization The court may consider on an expedited basis without a hearing requests for approval of the compromises of certain claims and actions or the disposition ofthe proceeds of certain judgments If your claim, action, orjudgment qualifies for expedited consideration and you want to request you must use form MC—350EX for your request. See Call Rules of Court, rule it. 7950.5. 1, Petitioner (name): DOHEtta EriCkson 2. ciaimant (name); Aaron Cattlett Hutsell, Jr. a. Address: 6570 Dee Lyle Circle, Casper, WY 82604 b. Date ofbirth:5/24/2003 c. Age: 15 d, Sex:Male e. Minor :1 Person withadisability 3, Relationship a. Parent g, E Petitioner's relationshiptothe claimant (check allapplicab/e boxes): Otherrelationship (specifyr) E E Guardian ad litem Guardian Conservator E] D Disabled adult claimantis (Ifyou checked item 3e or a petitioner. 3f, (See instructions for/‘tems 36 and 3fbe/ow.) Disabled adult claimant's express consent to the requested relief in on Attachment 3e or 3f showing state facts provided on Attachment 3t this petition is that the claimanthas capacity under Probate Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not have a conservator of the estate may petition or consent 1‘0 a petition. See Probate Code section 3613.) 4. Nature of claim The claim ofthe minor or adult person with a disability: a. b. D Has not been Is filedin an action or proceeding. (Complete items 5—23.) the subject of a pending action or proceeding thatwill be Name of court: compromised without a on the merits ofthe claim. trial Case no.: Trial date: (Complete items 5—23.) Page1of 1D Auerggginvwmgggg‘ggme PETITION To APPROVE COMPROMISE 0F DISPUTE!) CLAIM Codeovg;ggg{gcceggg-§§aggggg:33: WW“ Jumcaalooummrcanmrma “ma“! ‘1 201” 0R PENDING ACTION 0R DISPOSITION 0F PROCEEDS 0F Ca..Ru.esmcm mm“ JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY chl‘i’fii'cliil (Miscellaneous) MC—350 CASE NAME: CASE NUMBER: _ln Re: Aaron minor Cattlett Hutsell, Jr., a 4. c. D Nature of claim Is the defendants The claim of the minor or adult person with a disability: the subject of a pending action or proceeding that has named below in amount the total been or willbe reduced to a judgment for the claimant against and costs) of (specify below): (exclusive of interest s I Defendants (names! E Additional defendants listed on Attachment4. (Attach a E Thejudgmentwas filedon copy of the (proposed) judgment as Attachment 4c and complete items 13-23.) (date): 5. Incident or accident The incident or accident occurred as follows: a. Date and time; March 4, 2018, at 2:09am. b. pgace; Highway 168 inFresno County, California Q persons involved (names); Aaron Cattlett Hutsell, and Christian Montiel Martinez 6. D Continued on Attachment Nature of incident or accident 5. The and circumstances of the facts, events, incident or accident are (describe): Aaron had been Cattiett Hutsell drivingwestbound on Highway 168. east of Cedar Avenue, and was involved in a singIe—vehicle accident, A second vehicle, driven leaving his vehicle disabled with no lights on, just after a curve in the road. by Michael Dewar, then came around the curve and collided with Mr. Hutsell’s disabled vehicle. Following that collision, another vehicle. driven by Christian Montiel Martinez, came around the curve inthe highway and collided with Mr.Hutsell's vehicle. Mr.Hutsell sustained fatal injuries as a result. Itisunknown which specific collisioncaused the fatal injuries. E Continued on Attachment 6. 7. Injuries The were sustained by the claimant as a following injuries result of the incident or accident (describe): were sustained by decedent Aaron Hutsell, who is survived by two minor Fatal injuries children - Aaron Cattlett Hutsell, Jr., and Natasha whom are making wrongful death claims. Hutsell, both of E] Continued on Attachment E 7. 8. Treatment The claimant received the following careand treatment for the injuries described initem 7 (describe): E] Continued on Attachment 8. M0350lReV'JanuaW 1-20“! PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ”992m“ OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: 4n Re: Aaron Cattlett Hutsell, Jr.,a minor 9. E Extent of injuries and recovery and a for the claimant’s injuries, (An original or a photocopy of all doctors' reports containing a diagnosis of and prognosis must be attached report of the claimant’s present condition, as Attachment to this petition 9. A new repon‘ is not necessary so long as a previous a. E The claimant has recovered completely from report accurately describes the claimant's current condition.) the effects of the injuries described initem 7,and there are no b_ E permanent injuries, The claimant has not recovered completely from the effects of the injuries described from which the claimant has not recovered are temporary (describe the remaining in item7, injuries): and the followinginjuries E] Continued on Attachment 9b. 0. E: The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): E: Continued on Attachment 90. 10. Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner fully understands that if the compromise proposed in this petition is approved by the court and is consummated, the claimant will be forever barred from seeking any further recovery of compensation from the settling defendants named below even though the claimant's injuries may in the future appear to be more serious than they are now thought to be. 11. Amount and terms of settlement By way of settlement, the defendants named below have offered to pay the followingsums to the claimant: a. The total amount offered by all defendants named below is (specify): 5“2.50000 b. The defendants and amounts offered by each are as foliows (specify): Defendants (namesz Amounts Christian Montiel Martinez (vehicle driver) and Roberto Montie! (vehicle owner) $ 12,500.00 $ $ $ E C. Defendants and amounts offered continued on Attachment The terms of settlement are as follows 11. $ (if be paid in the settlementis to amount and installments, both the total the present value of the settlement must be included): Christian Montiel Martinezand Roberto Montiel have automobile insurance with CSAA Insurance, with a bodily injury CSAA policy limit of $25,000. Insurance and the Montiels have offered to resolve the wrongful death claims oanron Hutsell, and Natasha Jr., Hutsell for the policy with the $25,000 to be limit, equafly between the two split $12,500 heirs, at each, D Continued on Attachment 11. MC'350IReV-January1'2011l PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM PageSoHo OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: —~ln Re: Aaron Cattlett HutseH, Jr.,a minor 12. Settlement payments to others a. D No defendant named settle initem 11b has offered to pay same claims arising out of the money toany person or persons other than the claimant incident or accident that resulted inthe claimant's injury. to b. By way of settlement,one or more defendants named initem 11b have also offered to paymoney to aperson or persons other than claimant to same settle claims arising out of the incident or accident that resulted in the claimant's injury. _ The amount 121500-00 (1) (2) total Petitioner reimbursement is for not E offered byalldefendants to others (speciM: is $ a claimant against the recovery of the claimant (other than for expenses paid by petitioner and listed under item 15)‘ " (lfyou answered "is, explain in Attachment 12 the circumstances and theeffectyour claim has on the (3) proposed com Petitioner (If [fl is you answered ”is, not " E romise of the claim described in this petition.) is a same plaintiffin the action with the claimant. explain in Attachment 12 the circumstances and the effect your Claim and its disposition (4) E has on the proposed compromise of the claim or action described in this petition.) Petitionerwould receive money under the proposed settlement. (5) The settlement payments are tobe apportioned and distributed asfollows: Other plaintiffs or claimants (names) Amounts Natasha Hutsell (a minor) 12,500.00 $ $ $ E $ : and amounts are Additional plaintiffs or claimants listedon Attachment 12. (6) Reasons for the apportionment of the settlement payments between the claimant and each other or claimant named above are specified on Attachment 12. plaintiff E 13. The claimant's medical expenses, including medical expenses paid by petitionerand insurers, tobe reimbursed from proceeds of settlement orjudgment a. Totals (1) Totalmedicalexpenses: $ 0 (2) Total outstanding medical expenses tobe paid from the proceeds: $ (3) Total out—of-pocket, coapayments, or deductibte payments to be reimbursed from proceeds: $ I b. Medical expenses were paid and are to be reimbursed from proceeds as follows: E] Paid by petitionerinthe amountof: (1) (2) E Paid by private health insurance or a self—funded plan under: $ (a) D D An Employee Retirement Income An ERISA seIf—funded plan. Security Act (ERISA) insured plan. (b) (c) (d) E D A Non-ERISAinsured plan. A Non—ERISA seIf-funded plan. E ( e) Amount paid by plan: $ Amount of reimbursement to the plan from proceeds of settlement orjudgment: ( f) (i) E D No reimbursement Reimbursement is requested by the plan. be made (ii) (A) E E There isto is to the plan and: a contractual reduction of $ ( ) (B) (C) a E There No isa negotiated reduction of reduction has been agreed reimbursement to, $ ( ) for total amount to the plan in the of: $ MC-350IR6V- January 1'20“} PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page4°f1° OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: ~+n Re: Aaron Cattlett Hutsell, Jr.,a minor 13. The claimant's medical expenses, including medical expenses paid by petitionerand insurers, to be reimbursed from proceeds of settlement orjudgment b. Medical expenses were paid and are to be reimbursed from proceeds as follows: 3) [:3 Paid by Medicare inthe amount of: $ less the statutory reduction reimbursement for a total (Attach a copy of the to in theamount Medicare in of: the $ ( amount of: ) Medicare demand letter or letter agreement as Attachment $ [::: D Paid by Medi-Cal in final theamount of $ 13b(3).) E ) Notice of this claim or action has been given to the State Director of Health Care Services under Welfare a) and Code Institutions section 14124. 73.A copy ofthe notice and proof of delivery its D isattached (b) E [:1 was matter on (date). filed In this Notice ofthis claim or action has not been given to the State Director of Health Care Services (C) E (Explain inthe why notice has amount of: of In full satisfaction not been given its lien rights, inAttachment 13b(4).) Medi-Cal has agreed to accept reimbursement $ (Attach a copy of the final Medi—Caldemand letter or letter agreement as Attachment13b(4),) E E] Petitioneris ofthe Medi—Cal entitled to a reduction lienunder Welfare and Code Institutions (ii) E section E 14124.76 and: lsfiling amotion seeking a reduction ofthe Requests that the court reserve lien over jurisdiction concurrently with this petition. this issue. The amount ofthe lien indisputeis:$ There are one or more statutory or contractual medical service providers for payment of medical liens of expenses. The amount claimed under these total liensis: $ , In full satisfaction oftheir lien claims. the lienholders have agreed to accept the total sum of: $ (Provide requested information on each lienho/der and certain other medical service providers below‘) The name ofeach medical service provider and treatment to claimant and (1) has a lien for all that furnished care or any part of the charges or (2) was paid (or be paid from the proceeds) by petitioner for which petitioner will requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any; and the amount to be paid from the proceeds ofthe setttement orjudgment to each provider are as follows: (i)(A) Provider(name): (B) Address: (E) (C) Amount charged: $ (D) Amount paid (whether or not by insurance): $ ( ) (E) Negotiated reduction ifany: (F) Amount to be paid from proceeds of settlement orjudgment. $ (A) (ii) Provider(name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): $ ( ) (E) Negotiated reduction,ifany: $ ( Amount to be paid from proceeds of settlement orjudgment: $ E (F) Continued on Attachment 13b(5). (Provide information about additional providers including providers paid or to be paid above format, I'n the by petitioner for which reimbursement is requested in item 13b(1) above. You may use form MC—350(A—13b(5)) for thispurpose.) Mc-sso [Rem January 2011] 1, PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ”995““ OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: —~lnRe: Aaron a minor Cattlett Hutsell, Jr., 14‘ The claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement orjudgment a. Totalamount which court approval of attorney's fees for isrequested: $ fees are requested, (If attach as Attachment 14a,a declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal, Rules of Court. Respond to item 18a(2) on page 7 and attach a copy 0f any written attorney fee agreement as Attachment 18a.) b. The from the incident m MW $ $ M expense (other than medical expenses) have been incurred or paid, are reasonable, following additional items of resulted or accident, and shouid be paid out of claimant‘s share of the proceeds of the settlement orjudgment: $ $ $ D $ $ $ $ $ $ E] Continued on Attachment 14b. Total: $ Reimbursement of expenses paid by E 15. petitioner a. b. E has paid none ofthe claimant's expenses Petitioner has paid Petitioner reimbursement (orbecome items 13 and 14 for which reimbursement listed in obligated to pay) the following total amounts of the claimant'sexpenses isrequested. forwhich (1) (2) E D is requested. Medical expenses listed in item Attorney's fees includedin 13: amount shown in the total fee item 14a: $ $ (3) E: Other expenses included in shown in item the total 14b: $ (Attach proofs of the expenses incurred and payments made or obligations to pay incurred, orinvoices, 9.9., bills canceled checks, credit card statements, explanations of benefits from insurers, etc.) 16. Net balance of proceeds for the claimant The balance of theproceeds of the proposed settlement orjudgment remaining for the claimant afterpayment of requested fees and expenses is: all $ [12,500.00 17. Summary a. Gross amount of proceeds of settlement orjudgment for claimant: $ 12,500.00 b. Medical expenses to be paid from proceeds of settlement orjudgment: $ c. Attorney‘s fees to be paid from proceeds of settlement or judgment: $ d. Expenses (other than medical)to be paid from proceeds of settlement orjudgment: $ e. Total offees and expenses tobe paid from proceeds of settlement orjudgment f. (add (b),(o),and ((1)): Balance of proceeds of settlement or judgment available payment for claimant after of all $(0__m_) fees and expenses (subtract (e) from (a)): $ 12,500.00 MC‘35OIREV-Janua’y1v2m” PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM ”96W” OR PENDING ACTION OR DISPOSITION 0F PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER: —1n Re: Aaron Cattlett Hutsell, Jr., a minor 18. Information about attorney representing or assisting petitioner aA (1) [:j has not been represented or assisted by an attorney Petitioner in preparing this petition or in any other way with (Go to item 19.) respect to the claim asserted. has been represented or assisted by an attorney in preparing this petition orwith respect to the claim (2) Petitioner asserted. and the attorney Petitioner connection with the claim giving do not E rise to this petition.