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MC-350EX
ATTORNEY (Name, Stale Bar number, and address): IRT USE ONLY
Theodore Kreit, Esa. SBN: 271604
| Grossman Law Offices, APLC E-FILED
7161 N. Howard St. Ste. 202
Fresno, CA 9372 12/9/2019 11:05 AM
TELEPHONENO (559) 221-2261 FAXNO (Optiona(559) 226-3517 Superior Court of California
E-MAIL ADDRESS (Optional): County of Fresno
ATTORNEY FOR (Name) Claimant. BRANDON ALMARAZ-MARTINEZ By: C. York, Deputy
SUPERIOR COURT OF CALIFORNIA, COUNTY OF FRESNO
street appress |] 30 O Street
MAILING ADDRESS:
civ ano zie cove Fresno, CA 93724
BRANCH NAME
CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMER: 1 QC ECG 04418
EXPEDITED PETITION TO APPROVE: [EZ] No hearing date is requested.
(XJ) COMPROMISE OF DISPUTED CLAIM
[_] COMPROMISE OF PENDING ACTION
CI POSITION OF PROCEEDS OF JUDGMENT
DEPT, TIME:
Minor [_] Person With a Disability
NOTICE TO PETITIONERS
You must use this form if you wish to request expedited court approval of certain (1) compromises of disputed claims ofa minor,
(2) compromises of pending actions or proceedings in which a minor or a person with a disability (including a conservatee) is a party,
or (3) dispositions of the proceeds of judgments for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code,
§ 3500 et seq.) You may use this form if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f,
and either 3g(1) or 3g(2) below are true; and (3) the court does not otherwise order.
lf you qualify and choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or
judgment does not qualify for expedited treatment or you choose not to use this form, you must use the Petition to Approve
Compromise of Disputed Claim or Pending Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability
(form MC-350), and the court will schedule a hearing. See Cal. Rules of Court, rules 7,950, 7.950.5, and 7.951
Petitioner (name): Juana Martinez
Claimant (name)‘Brandon Almaraz-Martinez
a, Address: 1664 E. Chester Ave., Fresno, CA 93706
b, Date of birth:¢97/16/08 c. Age:]] d. Sex:Male e. Minor f. [-) Person with a disability
Expedited petition
a The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another.
b, No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust.
c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.
d. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the
claim is asserted or a party's insurance carrier.
Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.
All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court
has finally determined that all settling parties entered into the settlement in good faith.
(1) [3] The judgment for the claimant described in item 5c (exclusive of interest and costs) or the total of the settlement
described in items 12 and 13 payable to the claimant and all other persons named in item 13 is in the amount of
$50,000 or less; or
2 Gd The settlement described in item 12 represents payment of the single-person policy limits of all liability insurance
policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of
those defendants are judgment proof outside of their insurance coverage. (Describe investigation and results in
Attachment 3.) Page1 of 8
Fortn Ad ed fo EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Code of Civil Procedure § 372 et seq,
ternative Mi Probate Code, eq
Judicial Coun fornia CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS Cal Rules of Cour, rules 31384,
MC-350EX [New January 101, 7. @ 7.981
OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ww-courtinfo.ca gov
(Miscellaneous) Westlaw O0c& Form auger
MC-350EX
CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER:
L—
4. Relationship Petitioner's relationship to the claimant (check all applicable boxes).
Parent 9. [J Other relationship (specify)
Guardian ad litem
Guardian
Conservator
Disabled adult claimant is a petitioner. (See instructions for items 4e and 4f below.)
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 4f.
(if you checked item 4e or 4f, state facts on Attachment 4e or 4f showing that the claimant has 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 to a petition. See Probate Code section 3613.)
Nat of claim The claim of the minor or adult person with a disability:
{s not the subject of a pending action or proceeding. (Complete items 6-23.)
b. [1 Is the ‘subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
Name of court:
Case no, Trial date: (Complete items 6-23.)
c. [_] isthe subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against
the defendants named below in the total amount (exclusive of interest and costs) of (specify).
Defendants (names)
$| |
(J) Additional defendants listed on Attachment 5. [) The judgment was filed on (date).
(Attach a copy of the (proposed) judgment as Attachment 5c and complete items 14-23.)
Incident or accident
The incident or accident occurred as follows:
a, Date May 6, 2016 Time:6:50 p.m.
b. Place: SR-12 near SR-160, Sacramento County, CA
¢. Persons involved (names): Motor Vehicle Collision
Vehicle 1: Negligent driver and registered owner, Joseph Holdener
Vehicle 2: Laura Maria Rocha
Vehicle 3: Driver Juana Martinez (Petitioner herein); passengers Brandon Almaraz:
Martinez (Claimant herein), Christopher Martinez, and Jonathan Martinez.
[1 Continued on Attachment 6
7. CX] Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe).
Petitioner was driving a 2000 Honda Odyssey with her three children as passengers. The Odyssey was stopped
at a red light behind a 2005 Toyota Corolla driven by Laura Maria Rocha, which was also stopped. Negligent
driver Joseph Holdener rear-ended the Odyssey. The impact pushed the Odyssey into the Corolla.
Page 20f 8
New January 1, 201) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER:
L.
3 Cx Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Claimant initially experienced nausea and abdominal pain. This went away on its own within approximately 24 hours.
Thereafter, Claimant experienced neck pain for several weeks. He underwent 12 sessions of chiropractic care. By his last
session (10/14/16), the neck pain had gone away.
9. Treatment
The claimant received the following care and treatment for the injuries described in item 8 (describe):
Please sce Attachment 10 for a summary of Claimant’s medical treatment and copies of the medical records.
10. Extent of injuries and recovery (An original or a photocopy of all doctors’ reports containing a diagnosis of and prognosis
for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 10.
Anew report is not necessary so long as a previous report accurately describes the claimant's current condition.)
a GI The claimant has recovered completely from the effects of the injuries described in item 8, and there are no.
permanent injuries.
b, CI The claimant has not recovered completely from the effects of the injuries described in item 8, and the following
injuries from which the claimant has not recovered are temporary (describe the remaining injuries):
[=] Continued on Attachment 10b.
c. [] The claimant has not recovered completely from the effects of the injuries described in item 8, and the following
injuries from which the claimant has not recovered are permanent (describe the permanent injuries):
1 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 red; 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.
12. Amount and terms of settlement
By way of settlement, the defendants named below have offered to pay the following sums to the claimant:
a.
b.
The total amount offered by all defendants named below is (specify):
The defendants and amounts offered by each are as follows (specify):
s[aso000
Defendants (names) Amounts
Joseph Holdener (to be paid by Esurance) : 9.800.00
$
$
[1] Additional defendants and amounts offered are listed on Attachment 12.
c. The terms of settlement are described on Attachment 12. (/f the settlement is to be paid in installments, both the total
amount and the present value of the settlement must be included.)
MC-350EX Page 30f8
(New January1, 2010} EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER:
|
13, KX] Settlement payments to others
a. oo No defendant named in item 12b has offered to pay money to any person or persons other than the claimant to
settle claims arising out of the same incident or accident that resulted in the claimant's injury.
b. KC] By way of settlement, one or more defendants named in item 12b have also offered to pay money to a person or
persons other than claimant to settle claims arising out of the same incident or accident that resulted in the
claimant's injury.
(1) The total amount offered by all defendants to others (specify):
$20,200.00
(2) EX] Petitioner would receive money under the proposed settlement.
(3) The settlement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
Juana Martinez $ 15,000.00
Jonathan Martinez $ 1,200.00
Christopher Martinez $ 4,000.00
$
Co Additional plaintiffs or claimants and amounts are listed on Attachment 13.
@ CO The settlement payments are apportioned between the claimant and each other plaintiff or claimant
named above on a pro rata basis, based upon the special damages claimed by each. The special
damages claimed by each other plaintiff or claimant are specified on Attachment 13.
6 Ed Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 13
14, The claimant's medical expenses, including medical expenses paid by petitioner, Medicare, Medi-Cal, and private
insurers, that are to be reimbursed from proceeds of settlement or judgment
a. Totals
(1) Total expenses: $ 29,779.15
(2) Total amount paid (including payments by private insurance, Medi-Cal, or Medicare): $I 807.96 )
(3) Total of negotiated reductions, if any: 27,689.19 )
(4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 1,282.00
(5) Total amount of medical liens, if any: $ 1,282.00 (outstanding medical bills) plus $473.04 (Medi-Cal lien). Total: $1,775.04
(Identify each medical expense payer and the amount each paid, and explain any differences between items 14a(1), (4) and (5)
in Attachment 14a.)
b. (1) None of the claimant's medical expenses have been paid by Medicare.
(2) [_] Medicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights,
Medicare will be reimbursed in the amount of $
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 14b(2).)
(1) [1 None of the claimant's medical expenses have been paid by Medi-Cal.
(2) KX] Medi-Cal paid all or some or alll of the claimant's medical expenses.
(a) Notice of this claim or action has been given to the State Director of Health Care Services under Welfare and
institutions Code section 14124.73. A coy py of the notice and proof of its delivery Gd is attached.
Co was filed in this matter on (date):
(b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount of: s(__ 473.04]
(Altach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 14c(2).)
Co The claimant's health plan is requesting reimbursement for medical expenses paid under
the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ C7
(Attach statements from the plan showing expense payments and requesting reimbursement.)
[Petitioner has paid claimant's medical expenses to be reimbursed in the amount of
(See instructions for item 16.)
sC
1C-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page4 of8
(New January 1, 2010)
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER:
Lo
14, The claimant's medical expenses, including medical expenses paid by petitioner, Medicare, Medi-Cal, and private
insurers, that are to be reimbursed from proceeds of settlement or judgment
f. [x_] There are one or more liens from medical service providers for payment of claimant's medical expenses.
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: s[1,282.00]
g. (Select (1) or (2) below.)
(1) EXC] Latest statements from all medical service providers are attached as Attachment 14g.
(2) [_] All medical expenses have been paid by private insurance, Medicare, or Medi-Cal
15. The claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by
petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment
a, Total amount of attorney's fees for which court approval is requested: $
(If fees are requested, attach as Attachment 15a 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. Include a copy of any written attorney fee
agreement in Attachment 15a.)
b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or
judgment:
Items Payees (names) Amounts
Filing fee for instant petition Clerk of the Court 435.00
Claimant’s medical records Medic Ambulance 15.00
Claimant’s medical records Northbay Medical Center 15.00
Claimant’s medical records Chartswap 13.10
Claimant’s medical records UC Davis Medical Center 20.00
Claimant’s medical records Ciox Health 58.45
Claimant’s medical records Dr. Ajit Singh 25.00
[1] Continued on Attachment 15b. Total: Sa
c. [__] Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based
‘on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 15c.
16. Reimbursement of expenses paid by petitioner
a. LX] Petitioner has paid none of the claimant's expenses listed in items 14 and 15 for which reimbursement is requested.
b. [_] Petitioner has paid the following total amounts of the claimant's expenses for which reimbursement is requested.
(1) CJ Medical expenses listed in item 14: $
(2) [J Attorney's fees included in the total fee amount shown in item 15a: $
(3) Other expenses included in the total shown in item 15b:
(Attach proofs of the expenses incurred and payments made, e.g., bills or
invoices, canceled checks, credit card statements, explanations of benefits
SS
from insurers, etc.)
17. Net balance of proceeds for the claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment or
reimbursement of all requested fees and expenses is (specify): s[_
5,158.80
MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page
5 of 8
[New January 4, 2010]
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: Tn the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER.
L
18, Summary
a Gross amount of proceeds of settlement or judgment for claimant:
9,800.00
b. Medical expenses to be paid from proceeds of settlement
or judgment: $ 1,755.04
Attorney's fees to be paid from proceeds of settlement or
judgment: $ 2,304.61
Expenses (other than medical) to be paid from proceeds
of settlement or judgment: $ 581.55
Total of fees and expenses to be paid from proceeds of settlement or judgment
(add (b), (c), and (d)): $( 4,641.20 )
Balance of proceeds of settlement or judgment available for claimant after payment of all
fees and expenses (subtract (e) from (a)): s [5,158.80]
19. Information about attorney representing or assisting petitioner
a, The attorney [_] is not Kx] is representing or employed by any other party involved in this matter.
(if you answered "is," identify the other party and explain the relationship in Attachment 19a. If the other party is a defendant,
you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1
and Cal. Rules of Court, rule 7.950.5(a)(6).)
The attorney [1 has neither received nor expects to receive bd has received or expects to receive attorney's fees
or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise
to this petition (if you answered "has received or expects to receive," identify the person who paid or will pay the fees or other
compensation, the amounts paid or to be paid, and the dates of payment or expected payment):
‘rom Whom Paid or Expected (name): late Paid or Expecter Amount Paid or Expecte
Juana Martinez (via settlement with Defendant) November 2017 $ 4,623.79
Christopher Martinez (via settlement with Defendant) April 2019 1,000.00
Jonathan Martinez (via settlement with Defendant) April 2019 300.00
[) Continued on Attachment 19b, Tota: s[___5.923.74
20. Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows’
a. [__] There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a
disability filed in (name of court):
Case no.
MCs of the proceeds in money or other property will be paid or delivered to
the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money
or other property is specified in Attachment 20a(1).
2) C4 Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability.
Petitioner requests authority to deposit or invest $ of the money or other
property to be paid or delivered under 20a(1) with one or more financial institutions in this state or with a trust
company, subject to withdrawal only as authorized by the court. The money or other property and the name,
branch, and address of each financial institution or trust company are specified in Attachment 20a(2).
0X EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page
6 of 8
[New Jar y 1, 2010)
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER:
ba
20. Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows:
a There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability
(3) [1 Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or
conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows
(check all that apply):
@ Cs will be deposited in insured accounts in one or more financial
institutions in this state from which no withdrawals can be made without a court order,
The name, branch, and address of each depository are specified in Attachment 20a(3).
» CIs will be invested in a single-premium deferred annuity subject to
withdrawal only on order of the court. The terms and conditions of the annuity are specified in
Attachment 20a(3),
«CIs will be transferred to a custodian for the benefit of the minor under the
California Uniform Transfers to Minors Act. The name and address of the proposed custodian
and the property to be transferred are specified in Attachment 20a(3).
b. LX] There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability
Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check all
that apply):
(1) [J A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability
will be appointed. $ of money and other property will be paid or delivered to the
person so appointed. The money or other property are specified in Attachment 20b(1).
(2) $5,158.80 of money will be deposited in insured accounts in one or more financial
institutions in this state, subject to withdrawal only upon the authorization of the court. The name, branch,
and address of each depository are specified in Attachment 20b(2).
(3) $ of money will be invested in a single-premium deferred annuity, subject to
withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified
in Attachment 20b(3)
(4) $ will be paid or delivered to a parent of the minor, upon the terms and under the
conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the
parent and the money or other property to be delivered are specified in Attachment 20b(4).
(Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.)
(5) $ will be transferred to a custodian for the benefit of the minor under the California
Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other
property to be transferred are specified in Attachment 20b(5).
(6) $ of money will be held on such conditions as the court in its discretion determines
is in the best interest of the minor or the adult person with a disability. The proposed conditions are
specified on Attachment 20b(6). (Value must not exceed $20,000.)
(7) $ of property other than money will be held on such conditions as the court in its
discretion determines is in the best interest of the minor or the adult person with a disability. The proposed
conditions and the property are specified in Attachment 20b(7).
(8) Co $ will be deposited with the county treasurer of the County of (name):
The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h).
(9) CO $ will be paid or transferred to the adult person with a disability. The money or other
property is specified in Attachment 20b(9).
[1] Continued on Attachment 20
Mc-3506x EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page
7 of 8
[New January 1, 2010]
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350EX
CASE NAME: CASE NUMBER:
fe
21. Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to
the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise
settlement or proposed disposition and make such other and further orders as may be just and reasonable.
22. [_] Additional orders
Petitioner requests the following additional orders (specify and explain):
[1 Continued on Attachment 22.
23. Number of pages attached: —_——_
Date: {2/4 (4
Théejorg KNelT, ty.
(TYPE OR PRINT NAME OF ATTORNEY)
PAO.(SIGNATUREile JD
OF ATTORNEY)
| declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
tens
Juana (TYPE ORMartinez
PRINT NAME OF PETITIONER)
>
(SIGNATURE OF PETITIONER)
EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Pago
8 of 8
INew Sauary 12010)
CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-025
CASE NUMBER.
| SHORT TITLE: In the Matter of BRANDON ALMARAZ-MARTINEZ
ATTACHMENT (Number): 3
(This Attachment may be used with any Judicial Council form.)
3. Investigation Into Available Assets and Insurance
The negligent party in this case (Joseph Holdener) was covered by a minimum-limits automobile insurance
policy of $15,000.00 per person, $30,000.00 per occurrence (“15/30”). A copy of the declarations page
follows.
As confirmation, Claimant’s counsel obtained a sworn declaration from Mr. Holdener stating that there is no
other available insurance or assets. That declaration also follows.
Claimant’s counsel retained private investigator Charles Hallman to search for assets. He reported that Mr.
Holdener has no significant assets, and that he has in fact filed for bankruptcy multiple times.
Claimant’s counsel has also confirmed that there is no underinsured motorist coverage available for this
claim.
Accordingly, the only source of recovery available in this case is Mr. Holdener’s minimal 15/30 policy.
(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of 1
Attachment are made under penalty of perjury.)
(Add pages as required)
Form Approved for Optional Use ATTACHMENT www. courtinfo.ca.gov
Judicial Council of California Westlaw Doc & Form Builder=
MC-025 (Rev. duly 1, 2009] to Judicial Council Form
esurance’
Esurance Insurance Services, Inc. Esurance Property and
Casualty Insurance Company
P.O. Box 5250 650 Davis Street
Sioux Falls, SD 57117-5250 San Francisco, CA 94111
1-800-ESURANCE(1-800-378-7262)
Policy Declarations Page
Personal Automobile Policy — Amended
Policy Number Effective Date Expiration Date Policy Term
PACA-006517660 April 17, 2016 August 01, 2016@ 12:01 AM 6 Months
Year of
Named Insured and Address Rated Operators Excluded Drivers Driver Type Birth
JOSEPH HOLDENER 4 ia Holdener
Vehicle # Year Vehicle Description Vehicle Identification Number
1 2007 Kia OPTIMA LX/EX KNAGE124X75161648
2
icy Coverage is pro jed only where a premium and I or deducti le are shown.
Puncentoer ce Premium
BODILY INJURY 15,000/person
30,000/accdnt
PROPERTY DAMAGE 10,000/accdnt
UM BODILY INJURY
Vehicle 1 Vehicle 2 Vehicle Vehicle
Premium _Deductible| Premium Deductible Premium Deductible Premium Deductible]
as
UMPD/CDW
COMPREHENSIVE
eae
a
COLLISION
TOWING COVERAGE
RENTAL REIMBURSEMENT
Important: Please read your California Personal Auto Policy carefully as it contains language that will restrict or
exclude coverage, particularly to drivers of your vehicle who are not listed on the policy. The policy specifically
addresses who may use your vehicle and under what conditions coverage will be provided. In some cases, an
unlisted driver or permissive user will have liability limits reduced to the state’s minimum requirements,
which, in California are currently $15,000 per person / $30,000 per accident for both bodily injury and $5,000 for
property damage. You may purchase ad jonal coverage by contacting the company.
TOTAL CHANGE
=
This policy is effective at 12:01 AM on the date shown or the time the policy was purchased, whichever is later.
7001 CA 03 14 Page 1 of 2
DECLARATION OF JOSEPH HOLDENER
|, JOSEPH HOLDENER, declare and state that | am over the age of 18 years and competent to
testify to all the facts set forth herein, said facts being within my personal knowledge. If called upon to
testify, | could and would testify as follows:
Other than Esurance Property and Casualty Insurance Company Policy No. PACA-006517660
with bodily injury policy limits of $15,000.00 per person/$30,000.00 per occurrence, | am
unware of any other insurance policy which may provide coverage for the motor vehicle
collision of May 6, 2016 which I was involved in.
| have no significant assets, real or personal, which can be used to satisfy any additional
judgment beyond the policy limits of my insurance coverage set forth in paragraph one above. I
have insufficient assets to respond to a judgment in excess of the policy limits, or such assets
that | possess are protected by the applicable provisions of the United States bankruptcy laws.
At the time of the incident referred to in paragraph one, | was not acting as an agent for any
other entity or person, nor was | engaged in a joint venture with any other person or entity. |
was not on the job, and | was not doing any type of errand for any member of my family, for any
employer or any other person.
| understand that the person(s) claiming damages in the above-mentioned incident are relying
on the accuracy of this declaration (and the direct implication that there are no additional
monetary sources to enforce a higher settlement or judgment) in the decision to settle the case
for the policy limits.
| declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
Dated: {4/15 L019
‘wo witnesses to the signature are required:
Signature xf gaes CYh Signature
ob Wh Name LOA CL) Nae
He. Address = “Address
0
GS7AG ZO
|
Ingestion Date: 05 Nov 2019
a
Ingestion Date: 22 Nov 2019
MC-025
CASE NUMBER.
| SHORT TITLE: In the Matter of BRANDON ALMARAZ-MARTINEZ
ATTACHMENT (Number): 1(
(This Attachment may be used with any Judicial Council form.)
10. Extent of Injuries and Recovery
Attached hereto are copies of the following medical records of Claim
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MC-350EX ATTORNEY (Name, Stale Bar number, and address): IRT USE ONLY Theodore Kreit, Esa. SBN: 271604 | Grossman Law Offices, APLC E-FILED 7161 N. Howard St. Ste. 202 Fresno, CA 9372 12/9/2019 11:05 AM TELEPHONENO (559) 221-2261 FAXNO (Optiona(559) 226-3517 Superior Court of California E-MAIL ADDRESS (Optional): County of Fresno ATTORNEY FOR (Name) Claimant. BRANDON ALMARAZ-MARTINEZ By: C. York, Deputy SUPERIOR COURT OF CALIFORNIA, COUNTY OF FRESNO street appress |] 30 O Street MAILING ADDRESS: civ ano zie cove Fresno, CA 93724 BRANCH NAME CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMER: 1 QC ECG 04418 EXPEDITED PETITION TO APPROVE: [EZ] No hearing date is requested. (XJ) COMPROMISE OF DISPUTED CLAIM [_] COMPROMISE OF PENDING ACTION CI POSITION OF PROCEEDS OF JUDGMENT DEPT, TIME: Minor [_] Person With a Disability NOTICE TO PETITIONERS You must use this form if you wish to request expedited court approval of certain (1) compromises of disputed claims ofa minor, (2) compromises of pending actions or proceedings in which a minor or a person with a disability (including a conservatee) is a party, or (3) dispositions of the proceeds of judgments for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, § 3500 et seq.) You may use this form if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and either 3g(1) or 3g(2) below are true; and (3) the court does not otherwise order. lf you qualify and choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or judgment does not qualify for expedited treatment or you choose not to use this form, you must use the Petition to Approve Compromise of Disputed Claim or Pending Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing. See Cal. Rules of Court, rules 7,950, 7.950.5, and 7.951 Petitioner (name): Juana Martinez Claimant (name)‘Brandon Almaraz-Martinez a, Address: 1664 E. Chester Ave., Fresno, CA 93706 b, Date of birth:¢97/16/08 c. Age:]] d. Sex:Male e. Minor f. [-) Person with a disability Expedited petition a The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another. b, No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust. c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement. d. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court has finally determined that all settling parties entered into the settlement in good faith. (1) [3] The judgment for the claimant described in item 5c (exclusive of interest and costs) or the total of the settlement described in items 12 and 13 payable to the claimant and all other persons named in item 13 is in the amount of $50,000 or less; or 2 Gd The settlement described in item 12 represents payment of the single-person policy limits of all liability insurance policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of those defendants are judgment proof outside of their insurance coverage. (Describe investigation and results in Attachment 3.) Page1 of 8 Fortn Ad ed fo EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Code of Civil Procedure § 372 et seq, ternative Mi Probate Code, eq Judicial Coun fornia CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS Cal Rules of Cour, rules 31384, MC-350EX [New January 101, 7. @ 7.981 OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ww-courtinfo.ca gov (Miscellaneous) Westlaw O0c& Form auger MC-350EX CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER: L— 4. Relationship Petitioner's relationship to the claimant (check all applicable boxes). Parent 9. [J Other relationship (specify) Guardian ad litem Guardian Conservator Disabled adult claimant is a petitioner. (See instructions for items 4e and 4f below.) Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 4f. (if you checked item 4e or 4f, state facts on Attachment 4e or 4f showing that the claimant has 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 to a petition. See Probate Code section 3613.) Nat of claim The claim of the minor or adult person with a disability: {s not the subject of a pending action or proceeding. (Complete items 6-23.) b. [1 Is the ‘subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim. Name of court: Case no, Trial date: (Complete items 6-23.) c. [_] isthe subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant against the defendants named below in the total amount (exclusive of interest and costs) of (specify). Defendants (names) $| | (J) Additional defendants listed on Attachment 5. [) The judgment was filed on (date). (Attach a copy of the (proposed) judgment as Attachment 5c and complete items 14-23.) Incident or accident The incident or accident occurred as follows: a, Date May 6, 2016 Time:6:50 p.m. b. Place: SR-12 near SR-160, Sacramento County, CA ¢. Persons involved (names): Motor Vehicle Collision Vehicle 1: Negligent driver and registered owner, Joseph Holdener Vehicle 2: Laura Maria Rocha Vehicle 3: Driver Juana Martinez (Petitioner herein); passengers Brandon Almaraz: Martinez (Claimant herein), Christopher Martinez, and Jonathan Martinez. [1 Continued on Attachment 6 7. CX] Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe). Petitioner was driving a 2000 Honda Odyssey with her three children as passengers. The Odyssey was stopped at a red light behind a 2005 Toyota Corolla driven by Laura Maria Rocha, which was also stopped. Negligent driver Joseph Holdener rear-ended the Odyssey. The impact pushed the Odyssey into the Corolla. Page 20f 8 New January 1, 201) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER: L. 3 Cx Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Claimant initially experienced nausea and abdominal pain. This went away on its own within approximately 24 hours. Thereafter, Claimant experienced neck pain for several weeks. He underwent 12 sessions of chiropractic care. By his last session (10/14/16), the neck pain had gone away. 9. Treatment The claimant received the following care and treatment for the injuries described in item 8 (describe): Please sce Attachment 10 for a summary of Claimant’s medical treatment and copies of the medical records. 10. Extent of injuries and recovery (An original or a photocopy of all doctors’ reports containing a diagnosis of and prognosis for the claimant's injuries, and a report of the claimant's present condition, must be attached to this petition as Attachment 10. Anew report is not necessary so long as a previous report accurately describes the claimant's current condition.) a GI The claimant has recovered completely from the effects of the injuries described in item 8, and there are no. permanent injuries. b, CI The claimant has not recovered completely from the effects of the injuries described in item 8, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries): [=] Continued on Attachment 10b. c. [] The claimant has not recovered completely from the effects of the injuries described in item 8, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): 1 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 red; 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. 12. Amount and terms of settlement By way of settlement, the defendants named below have offered to pay the following sums to the claimant: a. b. The total amount offered by all defendants named below is (specify): The defendants and amounts offered by each are as follows (specify): s[aso000 Defendants (names) Amounts Joseph Holdener (to be paid by Esurance) : 9.800.00 $ $ [1] Additional defendants and amounts offered are listed on Attachment 12. c. The terms of settlement are described on Attachment 12. (/f the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.) MC-350EX Page 30f8 (New January1, 2010} EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER: | 13, KX] Settlement payments to others a. oo No defendant named in item 12b has offered to pay money to any person or persons other than the claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. b. KC] By way of settlement, one or more defendants named in item 12b have also offered to pay money to a person or persons other than claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. (1) The total amount offered by all defendants to others (specify): $20,200.00 (2) EX] Petitioner would receive money under the proposed settlement. (3) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts Juana Martinez $ 15,000.00 Jonathan Martinez $ 1,200.00 Christopher Martinez $ 4,000.00 $ Co Additional plaintiffs or claimants and amounts are listed on Attachment 13. @ CO The settlement payments are apportioned between the claimant and each other plaintiff or claimant named above on a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other plaintiff or claimant are specified on Attachment 13. 6 Ed Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 13 14, The claimant's medical expenses, including medical expenses paid by petitioner, Medicare, Medi-Cal, and private insurers, that are to be reimbursed from proceeds of settlement or judgment a. Totals (1) Total expenses: $ 29,779.15 (2) Total amount paid (including payments by private insurance, Medi-Cal, or Medicare): $I 807.96 ) (3) Total of negotiated reductions, if any: 27,689.19 ) (4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 1,282.00 (5) Total amount of medical liens, if any: $ 1,282.00 (outstanding medical bills) plus $473.04 (Medi-Cal lien). Total: $1,775.04 (Identify each medical expense payer and the amount each paid, and explain any differences between items 14a(1), (4) and (5) in Attachment 14a.) b. (1) None of the claimant's medical expenses have been paid by Medicare. (2) [_] Medicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights, Medicare will be reimbursed in the amount of $ (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 14b(2).) (1) [1 None of the claimant's medical expenses have been paid by Medi-Cal. (2) KX] Medi-Cal paid all or some or alll of the claimant's medical expenses. (a) Notice of this claim or action has been given to the State Director of Health Care Services under Welfare and institutions Code section 14124.73. A coy py of the notice and proof of its delivery Gd is attached. Co was filed in this matter on (date): (b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of: s(__ 473.04] (Altach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 14c(2).) Co The claimant's health plan is requesting reimbursement for medical expenses paid under the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ C7 (Attach statements from the plan showing expense payments and requesting reimbursement.) [Petitioner has paid claimant's medical expenses to be reimbursed in the amount of (See instructions for item 16.) sC 1C-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page4 of8 (New January 1, 2010) CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER: Lo 14, The claimant's medical expenses, including medical expenses paid by petitioner, Medicare, Medi-Cal, and private insurers, that are to be reimbursed from proceeds of settlement or judgment f. [x_] There are one or more liens from medical service providers for payment of claimant's medical expenses. In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: s[1,282.00] g. (Select (1) or (2) below.) (1) EXC] Latest statements from all medical service providers are attached as Attachment 14g. (2) [_] All medical expenses have been paid by private insurance, Medicare, or Medi-Cal 15. The claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment a, Total amount of attorney's fees for which court approval is requested: $ (If fees are requested, attach as Attachment 15a 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. Include a copy of any written attorney fee agreement in Attachment 15a.) b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts Filing fee for instant petition Clerk of the Court 435.00 Claimant’s medical records Medic Ambulance 15.00 Claimant’s medical records Northbay Medical Center 15.00 Claimant’s medical records Chartswap 13.10 Claimant’s medical records UC Davis Medical Center 20.00 Claimant’s medical records Ciox Health 58.45 Claimant’s medical records Dr. Ajit Singh 25.00 [1] Continued on Attachment 15b. Total: Sa c. [__] Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based ‘on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 15c. 16. Reimbursement of expenses paid by petitioner a. LX] Petitioner has paid none of the claimant's expenses listed in items 14 and 15 for which reimbursement is requested. b. [_] Petitioner has paid the following total amounts of the claimant's expenses for which reimbursement is requested. (1) CJ Medical expenses listed in item 14: $ (2) [J Attorney's fees included in the total fee amount shown in item 15a: $ (3) Other expenses included in the total shown in item 15b: (Attach proofs of the expenses incurred and payments made, e.g., bills or invoices, canceled checks, credit card statements, explanations of benefits SS from insurers, etc.) 17. Net balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment or reimbursement of all requested fees and expenses is (specify): s[_ 5,158.80 MC-350EX EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 5 of 8 [New January 4, 2010] CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: Tn the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER. L 18, Summary a Gross amount of proceeds of settlement or judgment for claimant: 9,800.00 b. Medical expenses to be paid from proceeds of settlement or judgment: $ 1,755.04 Attorney's fees to be paid from proceeds of settlement or judgment: $ 2,304.61 Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ 581.55 Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): $( 4,641.20 ) Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (a)): s [5,158.80] 19. Information about attorney representing or assisting petitioner a, The attorney [_] is not Kx] is representing or employed by any other party involved in this matter. (if you answered "is," identify the other party and explain the relationship in Attachment 19a. If the other party is a defendant, you must use form MC-350 for your petition and are not eligible for expedited consideration by the court. See item 3e on page 1 and Cal. Rules of Court, rule 7.950.5(a)(6).) The attorney [1 has neither received nor expects to receive bd has received or expects to receive attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition (if you answered "has received or expects to receive," identify the person who paid or will pay the fees or other compensation, the amounts paid or to be paid, and the dates of payment or expected payment): ‘rom Whom Paid or Expected (name): late Paid or Expecter Amount Paid or Expecte Juana Martinez (via settlement with Defendant) November 2017 $ 4,623.79 Christopher Martinez (via settlement with Defendant) April 2019 1,000.00 Jonathan Martinez (via settlement with Defendant) April 2019 300.00 [) Continued on Attachment 19b, Tota: s[___5.923.74 20. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows’ a. [__] There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability filed in (name of court): Case no. MCs of the proceeds in money or other property will be paid or delivered to the guardian of the estate of the minor or the conservator of the estate of the conservatee. The money or other property is specified in Attachment 20a(1). 2) C4 Petitioner is the guardian or conservator of the estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ of the money or other property to be paid or delivered under 20a(1) with one or more financial institutions in this state or with a trust company, subject to withdrawal only as authorized by the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 20a(2). 0X EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 6 of 8 [New Jar y 1, 2010) CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: In the Matter of BRANDON ALMARAZ-MARTINEZ CASE NUMBER: ba 20. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows: a There is a guardianship of the estate of the minor or a conservatorship of the estate of the adult person with a disability (3) [1 Petitioner proposes that all or a portion of the proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check all that apply): @ Cs will be deposited in insured accounts in one or more financial institutions in this state from which no withdrawals can be made without a court order, The name, branch, and address of each depository are specified in Attachment 20a(3). » CIs will be invested in a single-premium deferred annuity subject to withdrawal only on order of the court. The terms and conditions of the annuity are specified in Attachment 20a(3), «CIs will be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are specified in Attachment 20a(3). b. LX] There is no guardianship of the estate of the minor or conservatorship of the estate of the adult person with a disability Petitioner requests that the balance of the proceeds of the settlement or judgment be disbursed as follows (check all that apply): (1) [J A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability will be appointed. $ of money and other property will be paid or delivered to the person so appointed. The money or other property are specified in Attachment 20b(1). (2) $5,158.80 of money will be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only upon the authorization of the court. The name, branch, and address of each depository are specified in Attachment 20b(2). (3) $ of money will be invested in a single-premium deferred annuity, subject to withdrawal only upon the authorization of the court. The terms and conditions of the annuity are specified in Attachment 20b(3) (4) $ will be paid or delivered to a parent of the minor, upon the terms and under the conditions specified in Probate Code sections 3401-3402, without bond. The name and address of the parent and the money or other property to be delivered are specified in Attachment 20b(4). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) (5) $ will be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 20b(5). (6) $ of money will be held on such conditions as the court in its discretion determines is in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 20b(6). (Value must not exceed $20,000.) (7) $ of property other than money will be held on such conditions as the court in its discretion determines is in the best interest of the minor or the adult person with a disability. The proposed conditions and the property are specified in Attachment 20b(7). (8) Co $ will be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specified in Probate Code section 3611(h). (9) CO $ will be paid or transferred to the adult person with a disability. The money or other property is specified in Attachment 20b(9). [1] Continued on Attachment 20 Mc-3506x EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Page 7 of 8 [New January 1, 2010] CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350EX CASE NAME: CASE NUMBER: fe 21. Petitioner recommends the compromise settlement or the proposed disposition of the proceeds of the judgment for the claimant to the court as being fair, reasonable, and in the best interest of the claimant and requests that the court approve this compromise settlement or proposed disposition and make such other and further orders as may be just and reasonable. 22. [_] Additional orders Petitioner requests the following additional orders (specify and explain): [1 Continued on Attachment 22. 23. Number of pages attached: —_——_ Date: {2/4 (4 Théejorg KNelT, ty. (TYPE OR PRINT NAME OF ATTORNEY) PAO.(SIGNATUREile JD OF ATTORNEY) | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: tens Juana (TYPE ORMartinez PRINT NAME OF PETITIONER) > (SIGNATURE OF PETITIONER) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED Pago 8 of 8 INew Sauary 12010) CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-025 CASE NUMBER. | SHORT TITLE: In the Matter of BRANDON ALMARAZ-MARTINEZ ATTACHMENT (Number): 3 (This Attachment may be used with any Judicial Council form.) 3. Investigation Into Available Assets and Insurance The negligent party in this case (Joseph Holdener) was covered by a minimum-limits automobile insurance policy of $15,000.00 per person, $30,000.00 per occurrence (“15/30”). A copy of the declarations page follows. As confirmation, Claimant’s counsel obtained a sworn declaration from Mr. Holdener stating that there is no other available insurance or assets. That declaration also follows. Claimant’s counsel retained private investigator Charles Hallman to search for assets. He reported that Mr. Holdener has no significant assets, and that he has in fact filed for bankruptcy multiple times. Claimant’s counsel has also confirmed that there is no underinsured motorist coverage available for this claim. Accordingly, the only source of recovery available in this case is Mr. Holdener’s minimal 15/30 policy. (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of 1 Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use ATTACHMENT www. courtinfo.ca.gov Judicial Council of California Westlaw Doc & Form Builder= MC-025 (Rev. duly 1, 2009] to Judicial Council Form esurance’ Esurance Insurance Services, Inc. Esurance Property and Casualty Insurance Company P.O. Box 5250 650 Davis Street Sioux Falls, SD 57117-5250 San Francisco, CA 94111 1-800-ESURANCE(1-800-378-7262) Policy Declarations Page Personal Automobile Policy — Amended Policy Number Effective Date Expiration Date Policy Term PACA-006517660 April 17, 2016 August 01, 2016@ 12:01 AM 6 Months Year of Named Insured and Address Rated Operators Excluded Drivers Driver Type Birth JOSEPH HOLDENER 4 ia Holdener Vehicle # Year Vehicle Description Vehicle Identification Number 1 2007 Kia OPTIMA LX/EX KNAGE124X75161648 2 icy Coverage is pro jed only where a premium and I or deducti le are shown. Puncentoer ce Premium BODILY INJURY 15,000/person 30,000/accdnt PROPERTY DAMAGE 10,000/accdnt UM BODILY INJURY Vehicle 1 Vehicle 2 Vehicle Vehicle Premium _Deductible| Premium Deductible Premium Deductible Premium Deductible] as UMPD/CDW COMPREHENSIVE eae a COLLISION TOWING COVERAGE RENTAL REIMBURSEMENT Important: Please read your California Personal Auto Policy carefully as it contains language that will restrict or exclude coverage, particularly to drivers of your vehicle who are not listed on the policy. The policy specifically addresses who may use your vehicle and under what conditions coverage will be provided. In some cases, an unlisted driver or permissive user will have liability limits reduced to the state’s minimum requirements, which, in California are currently $15,000 per person / $30,000 per accident for both bodily injury and $5,000 for property damage. You may purchase ad jonal coverage by contacting the company. TOTAL CHANGE = This policy is effective at 12:01 AM on the date shown or the time the policy was purchased, whichever is later. 7001 CA 03 14 Page 1 of 2 DECLARATION OF JOSEPH HOLDENER |, JOSEPH HOLDENER, declare and state that | am over the age of 18 years and competent to testify to all the facts set forth herein, said facts being within my personal knowledge. If called upon to testify, | could and would testify as follows: Other than Esurance Property and Casualty Insurance Company Policy No. PACA-006517660 with bodily injury policy limits of $15,000.00 per person/$30,000.00 per occurrence, | am unware of any other insurance policy which may provide coverage for the motor vehicle collision of May 6, 2016 which I was involved in. | have no significant assets, real or personal, which can be used to satisfy any additional judgment beyond the policy limits of my insurance coverage set forth in paragraph one above. I have insufficient assets to respond to a judgment in excess of the policy limits, or such assets that | possess are protected by the applicable provisions of the United States bankruptcy laws. At the time of the incident referred to in paragraph one, | was not acting as an agent for any other entity or person, nor was | engaged in a joint venture with any other person or entity. | was not on the job, and | was not doing any type of errand for any member of my family, for any employer or any other person. | understand that the person(s) claiming damages in the above-mentioned incident are relying on the accuracy of this declaration (and the direct implication that there are no additional monetary sources to enforce a higher settlement or judgment) in the decision to settle the case for the policy limits. | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: {4/15 L019 ‘wo witnesses to the signature are required: Signature xf gaes CYh Signature ob Wh Name LOA CL) Nae He. Address = “Address 0 GS7AG ZO | Ingestion Date: 05 Nov 2019 a Ingestion Date: 22 Nov 2019 MC-025 CASE NUMBER. | SHORT TITLE: In the Matter of BRANDON ALMARAZ-MARTINEZ ATTACHMENT (Number): 1( (This Attachment may be used with any Judicial Council form.) 10. Extent of Injuries and Recovery Attached hereto are copies of the following medical records of Claim