Preview
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021
EXHIBIT B
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021
83/09/Z1 13:19 M6 AI lstate_RFC -> 518 587 BZ69 Al1state Insurance C Page 883
RELEASE OF ALL CLAIMS
CLAIM # Z8322330
This Indenture Witnesseth that, in consideration of the sum of One hundred thousand dollars(S*Settlement
100,000), receipt whereof is hereby acknowledged, for myself and for my heirs, personal representatives and
assigns, I do hereby release and forever discharge Arthur R Smith, Julie A Smith, Emily Smith, Encompass Home
and Auto Insurance Company and any other person, finn or corporation charged or chargeable with responsibility
or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses,
loss of services, actions and causes of action, arising from any act or occurrence up to the present time and
particularly on account of all personal injury, disability, property damages, loss or damages of any kind already
sustained or that I may hereafter sustain in consequence of an accident that occurred on or about the 24th day of
June, 2020, at or near Pultney St, Whitehall, NY.
To procure payment of the said sum, I hereby declare: that I am more than 18 years of age; that no representations
about the nature and extent of said injuries, disabilities or damages made by any physician, attorney or agent of
any party hereby release, nor any representations regarding the nature and extent of legal liability or financial
responsibility of any of the parties release, have induced me to make this settlement; that in determining said sum
there has been taken into consideration not only the ascertained injuries, disabilities and damages, but also the
possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and
indefinite, so that consequences not now anticipated may result from the said accident.
I hereby agree that, as a further consideration and inducement for this compromise settlement, that it shall apply
to all unknown and unanticipated injuries and damages resulting from said accident, casualty or event, as well as
to those now disclosed.
I further understand that I admit no liability of any sort by reason of said accident and that said payments and
settlements in compromise is made to terminate further controversy respecting all claims for damages that I have
heretofore asserted or that I or my personal representatives might hereafter assert because of said accident.
I further understand that such liability as I may or shall have incurred, directly or indirectly, in connection with or
for damages arising out of the accident to each person or organization, release and discharge of liability herein,
and to any other person or organization, is expressly reserved to each of them, such liability not being waived,
agreed upon, discharged nor settled by the release.
The undersigned expressly covenants and warrants that all Medicare, Medicare Advantage Organization,
Medicare Advantage Plan, and/or Medicaid, hospital, medical provider, health care provider, medical supplier and
other medical liens, subrogation rights, rights of payment, rights of reimbursement and claims of any nature
whatsoever, arising now or in the future, as a result of health care services provided to the undersigned have been
or will be satisfied, settled, compromised byor paid express agreement
Medicare, Medicare
with Advantage
Organization, Medicare Advantage Plan, and/or Medicaid, each insurance carrier and each hospital, health care
provider, medical provider or medical supplier by the undersigned prior to final disbursement of the settlement
proceeds. The undersigned covenants
and warrants that all such claims, liens, payment obligations and
assigmnents have beenWsclosed
in writing to the parties released prior to settlement. The undersigned agrees to
indemnify, defend and hold harmless the parties released for any and all losses, claims, demands or causes of
action, and any damages, judgments, fees, expenses, costs (including interest) of any nature whatsoever paid and
incurred as a result of any breach of these wan·anties and covenants. The undersigned understands and agrees that
. the parties releaseyl have relied on these material representpions as part of the consideration and inducemènt for
this settlement.
The nudersigned uriderstands and agrees that such liability as he/she may or shall have mcurred, ansing now or in
the future, as a result of health care services provided to the undersigned, including any health care lien, statutory
or otherwise, is expressly reserved to each and every health care provider or payor based on such services, such
Z8322330 SE Initials
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021
83 / B9/ 21 13t28187 A IIstate-RFC 4 518 587 8269 91Istate Insurance C Page 884
liability not being in any way waived, agreed apon, discharged, released or settled or impacted in anyway, by this
rdease. This specificany includes, but is not limited to, any fiability the ondersigned rñay have to any hospital,
health care provider, medical provider, medical agpplier, Medicar4 Medicare Adfantage Organization, Medicare
Advantage Plan, and/or Medicaid. Jf any subrogation claimsdiens or rights to payment of any kind against these
settlement proceeds do in fact exist, the undersigned shall distribute these fúnds in accord with such elaims, liens
or rights to payment (or shalf direct his/her attomey to do so) The undersigned agrees tö indemnify, defend and
hold harmless the parties released forany and alhosses, claims, dõmands or causes of action, and any damages,
judgments, feesa expenses, costs (including interest) of any nature what«áever paid and incurred as a resuh of any
breach of these lagreements and covenants, The undersigned understands and agrees that the parties released have
relied on these materialrepresentations as piart of the consideration and inducement for this settlement.
Any person who knowingly and withintent to defraud any insurance company or other person files an application for
insurance or statement of gIaim containing any materially falsedaferisationror conceals for the purpose of
misleading, informAtion concerning any factniaterial thereto, commitsy frandolent insurance act, which is a crime,
and shaH also be subje¢tto a civilpenalty not to exceed flye t pugM4ollars andthe stated value of the claim for each
such violatfâñ.
Aute Claims Only:sny person who knowingly makes or knowingly assists, abees, solicitt er conspires with
another to make$ false report of the theft, destructionatantage Weeritersion of any motor vehicle fo a law
enforcement.agency, the department of aptor rehkl6s Wan insurghee company, enanüts a fraudulere insurahee act,
which b a wimef and shall also be aub ect to a civil pe¼ielty not to exceedl ive thousand dolla&add the value of the
subject motor vehlete or stated
(CAUTIQN-READ BEFORR SIGNINGy
SIGNED AND 5FALED THIS AT UF ,
S gn ture
Witnessed y:
COUNTY OF b004 6Yi
On this day of , before nie personally appear
03_, to me known to Be the pgrsoris he executed the foregoing
instrunient, and acknow edged that they executed thecsame as their fred act add deed
My coranzisslon ex ires 21a3 5tia lhibirlaw-
NoWFPublié
HOLLY A. RABlDEAU
Notary Public - State of New York
No. 01RA6161693
Qualified in Essex County
My Commission Expires Feb. 26, 20
GIINF009 Z8322s30 SE Initials
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
NYSCEF DOC. NO.
83/89/21 4
13:19: 46 AI Istate RFC -> 518 587 8269 Al 1state RECEIVED
Insurance NYSCEF: 04/12/2021
C Page 883
RELEASE OF ALL CLAIMS
CLAIM # Z8322330
This Indenture Witnesseth that, in consideration of the sum of One hundred thousand dollars ($*Settlement
100,000), receipt whereof is hereby acknowledged, for myself and for my heirs, personal representatives and
assigns, I do hereby release and forever discharge Arthur R Smith, Julie A Smith, Emily Smith, Encompass Home
and Auto Insurance Company and any other person, firm or corporation charged or chargeable with responsibility
or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses,
loss of services, actions and causes of action, arising from any act or occurrence up to the present time and
particularly on account of all personal injury, disability, property damages, loss or damages of any kind already
sustained or that I may hereafter sustain in consequence of an accident that occurred on or about the 24th day of
June, 2020, at or near Pultney St, Whitehall, NY.
To procure payment of the said sum, I hereby declare: that I am more than 18 years of age, that no representations
about the nature and extent of said injuries, disabilities or damages made by any physician, attorney or agent of
any party hereby release, nor
any representations regarding the nature liability and extent of legal or financial
responsibility of any of the parties release, have induced me to make this settlement, that in determining said sum
there has been taken into consideration not only the ascertained injuries, disabilities and damages, but also the
possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and
indefinite, so that consequences not now anticipated may result from the said accident.
I hereby agree that, as a fm-ther consideration and inducement for this compromise settlement, that it shall apply
to all unknown and unanticipated injuries and damages resulting from said accident, casualty or event, as well as
to those now disclosed.
I further understand that I admit no liability of any sort by reason of said accident and that said payments and
settlements in compromise is made to terminate further controversy respecting all claims for damages that I have
heretofore asserted or that I or my personal representatives might hereafter assert because of said accident.
I fmther understand that such liability as I may or shall have incurred, directly or indirectly, in connection with or
for damages arising out of the accident to each person or organization, release and discharge of liability herein,
and to any other person or organization, is expressly reserved to each of them, such liability not being waived,
agreed upon, discharged nor settled by the release.
The undersigned expressly covenants and warrants that all Medicare, Medicare Advantage Organization,
Medicare Advantage Plan, and/or Medicaid, hospital, medical provider, health care
provider, medical supplier and
other medical liens, subrogation rights, rights of payment, rights of reimbursement and claims of any nature
whatsoever, arising now or in the future, as a result of health care services provided to the undersigned have been
or will be satisfied, settled, compromised or paid by express agreement with Medicare, Medicare Advantage
Organization, Medicare Advantage Plan, and/or Medicaid, each carrier insurance
hospital, health care and each
provider, medical provider or medical supplier by the undersigned prior to final disbursement of the settlement
proceeds. The undersigned covenants and warrants that all such claims, liens, payment obligations and
assigmnents have been disclosed in writing to the parties released prior to settlement. The undersigned agrees to
indemnify, defend and hold harmless the parties released for any and all losses, claims, demands or causes of
action, and
any damages, judgments, fees, expenses, costs (including interest) of any nature whatsoever paid and
incurred as a result of any breach of these warranties and covenants. The undersigned understands and agrees that
the parties released have relied on these material representations as part of the consideration and inducement for
this settlement.
The undersigned understands and agrees that such liability as he/she may or shall have incurred, arising now or in
the future, as a result of health care services provided to the undersigned, including any health care lien, statutory
or otherwise, is expressly reserved to each and every health care provider or payor based on such services, such
Z8322330 SE Initials
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
NYSCEF DOC. NO.
83/09/21 4
13:Z8:07 Al Istate-RFC -> 518 587 8Z69 A1Istate RECEIVED
Insurance NYSCEF: 04/12/2021
C Page 884
liability not in any way waived,
being agreed upon, discharged, released or settled or impacted in anyway, by this
release. This
specifically includes, but is not limited to, any liability the undersigned may have to any hospital,
health care provider, medical provider, medical supplier, Medicare, Medicare Advantage Organization, Medicare
Advantage Plan, and/or Medicaid. If any subrogation claims, liens or rights to payment of any kind against these
settlement proceeds do in fact exist, the undersigned shall distribute these funds in accord with such claims, liens
or rights to payment (or shall direct his/her attorney to do so). The undersigned agrees to indemnify, defend and
hold hannless the parties released for any and all losses, claims, demands or causes of action, and any damages,
judgments, fees, expenses, costs(including interest) of any nature whatsoever paid and incurred as a result of any
breach of these agreements and covenants. The undersigned understands and agrees that the parties released have
relied on these material representations as part of the consideration and inducement for this settlement.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statemcat of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a frauda:cat insurance act, which is a crime,
and shall also be subject to a civil penalty not to exceed five thensand dollars and the stated value of the claim for each
such violation.
Auto Claims Only: Any person who knewingly makes or knowingly assists, abets, solicits or conspires with
another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law
enforcement agency, the department of motor vehicles or an insurance cc:ni-any, commits a fraudulent insurance act,
which is a crime, and shall also be subject to a civil penalty not to exceed five thensand dollars and the value of the
subject motor vehicle or stated.
(CAUTION-READ BEFORE SIGNING)
SIGNED AND SEALED THIS DAY OF At r , O
Signature
O (Seal) o
Name printed
Witnessed by:
STATE OF Swa (K
y
COUNTY OF &
On this day of , 202J , before me personally appeared
(bfCGdon Q 0 g, , to me known to be the persons who executed the foregoing
instrument, and acknowledged that they executed the same as their free act and deed.
My commission expires CXc a9 a3 myÅ4LÊ AÅ sQ{
Notary Public
KlMBERLY A. WILSON
NotaryP ublic State of New York
No. 01Wl5079583
Qualified in Saratoga Cot nty
Comrnission Expires_ _qi 3
GENF009 Z8322330 SE Initials
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
P NYSCEF:F-669
07-14-'20 08:47 FROM-whitehall PD 5184993570 T-447 P0005/0005
NYSCEF DOC. NO. 4 RECEIVED 04/12/2021
'°°ª'°°°ªª
POUICEACÖÏDEN TREPORT
7 MV-104A (6/04)
RMOYGTRTEUER DMV COPY
AnoldentDate .__ Dayof Week MilharyTime No.af No.InjuredKilled NotInvestiOBIGd atScGne LeftScene PolicePhotos
M as Y Veh as ---------------------------- g
AccidentReepnehucted Û Yes 0
VEHICLE 1 O VEHICLE2 D BlCYCLIST & PEDESTRIAN O OTHERPEDESTRIAN
VEHCLE1 - DFNer Stateof Uc. VEHICLE 2- Onver StateofUc.
2 LicenseIDNumber I.icense10Number 21
DdverName-exactly DriverName- exactly
asDrintedon\lconso asprintedonlicense
Address Apt.No. Address Apt No,
8 S Unifcensed No.of blic Sex Unlicensed No.of Public
Occupants roperty r Occupants Pmperty
amaacd D Damaged
-- - ah
N me-exactlyas p iod roofst ti Sex asprintedonregistration
Name-exactly Sex
Month Day Year ' Month Day Year
Address( Number& Street) Apt.No. Her. Released Address(/ncludeNumber& Street) Apt.No. Haz. Released
4 Mat Mat.
Cityo s city orTown State Zfp Cods 24
S Reo. V aYear& Make VeNcle PlateNumber StateofRs0. VehicleYear& Make VehicleType na.Code
cket/Arrest 'ficket/Arrest
Number(s) Numoer(s)
Violation Violellon
Section(s) Section(s)
Check If involved vehicle is: Check II involved vehicle Is: Circle the diagram below that describes the accident, or arawyour own
O more than 95 inches wide; O more than 98 Inches wide; diagramin space #9. Number the vehicles.
V D more than 34 feet long; V O more than 34 feet long: RightAngle RightTurn HeadOn
RearUnd Left m
E O operated with an overweight permíl: E O operated with an overweight permit; '4-
H O operated With an overdimension permit. H O opersitedwith an ovemi=ndon permit.
VEHICLE 1 DAMAGE CODES ( VEHICLE 2 DAMAGE CCDES Sideswi SideswIpe 26
4
LeftTum RightTum.
- C 2 c Box 1 - Point of Impact 1 2 (same scuon) (oppoeno
direction) .
Box 1 - Point of Impact ++
L Box 2- Most Damage L Box 2 - Most Damage 2. Ý•- o a a f n
E Enter up to three 3 4 5 E Enter up to three 8 4 g ACCIDENT DIAGRAM
more Darnage Codes mate Damage Codes
Vehicio Sy Vehicle By
Towed: Towed
To To
VEl-ffCLE DAMAGE CODING:
1-13, SEE DIAGRAM ON RIGHT.
14. UNDERCARRIAGE 17. DEMOLISHED
15. TRAILER 18. NO DAMAGE 28
16. OVERTURNED 19. OTHER Cost of repairs to any one vs hicle will be more than $1000.
n ) n n Unknown!Unable to Deterrnine Yes ¤ No
Reference Marker Coordinates (if available) P ace Wiiefe A c dent Occurred: .
Latitude/Northing: County O City Village O Town of ,
Roadon whfchaccidentoccurred M
(RouteNumberor StreetName)
at1) intersectingstreet. . Î , [
- -
Longitude/Easting: (RouteNumberorStreetName)
DN S
or 2) O E O W of
I'eet Miles (MUepost RouteNumberorstreet
NearestIntemectina Name)
Accident Description/0fficer's Notes so
c (
8 9 10 11 12 13 14 15 16 17 BY TO 18 Names of all inv Ived Dateof Death 2nly_
0 O . .. ..-.
V E
D
Oficed Rank Badge/ID No. NCIC No. Precinct/Pos Station/Beat/ Rev wing Date fime Reviewed
and Signature Troop/Zone Sector icer
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
07-14-'20 08:46 FROM-whitehall PD 5184993570 T-447 P0002/0005 F-669
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021
1. Agency 2. piv/Precinct 3. ORI 5. CaseNo, 6. Incident No.
VILLAGE OF WHITEHALL . NY0572800 20-31748 31748
7,8,9.Date Reported (Day, Date, Time) 10,1012, Occurred On/Froin (Day Date Time) 13,14,I5. Occurred To (Day, Date, Time)
WEDNESDAY 06/24/2020 I8:30 WEDNESDAY 06/24/2020 18:30
16. In cident Type 17. BusinessName
ACCIDENT-PERSONAL INJURY
19. Incident Address (Street Name, Bidg. No., fi ii-No-)
POULTNEY STREET
20. Ci¼/State/Zip
WHITEHALL NEW YORK 12887-0000
21. Location Code (TSLED) 23. No. of Victims 24. No.otSuspects 26, Victim also Cc:::p!±:::t?
WHITEHALL VILLAGB 5828 0 0 No
Location Type
ASSOCIATEDPERSONS
VEHICLE SMITH, EMILY A egfR/2001 RABBAAAWN1BlP
OPERATOR
WITNESS KELLEY, PATRICK M SR 5E8/1966 (518
WH(TEHALL NY 12887
WITNESS BOLTON, JONATHON B /1985 (518)
BLDO 128APT C WH1TEHALL NY 12887
VICTIM .M /2007
WHITEHALL NY
VICTIM
Name 27. DOB 28. Age 29. Cender 30 Race 31. Ethnicity 32.Handicap 33. ResidenceStatus
AnggnngnhM /2007 13 PEMALE WHITE NOTHISPANIC
Victim DID receive i=fo=a:ffo:: on Victim's Rights and Services pursuant to New York State Law O Yes El No
VEHICLE
59. Vehicle Status 60. License Plate No. 61. State 62. Exp, Yr. 64. Value
OBSERVED FEY5016 NY $0.00
63. Plate Type 65. Year 66. Make 67. Model
PASSENGER AUTOMOBILE (kEGULAR PLATES) 2016 HONDA CRV
68.Style 69. VIN 70. Color(s)
71a. Towed By 71b. Towed To
72. Vehicle Notes
DAMAGE LEFT FRONT PENDER
Page 1 of 2 07/14/2020 07:27:10
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724
07-14-'20 08:46 FROM-whitehall PD 5184993570 T-447 P0003/0005 F-669
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021
NARRATIVE
Date of Action Date Written Officer Name & Rank
06/24/2020 06/24/2020 HUMPHRiBS, WILLIAM(PATROLMAN)
Narrative
On todays dateI respondedto a one car vs. personMVA at the intersectionof Poultney and SouthWilliams streets.Upon arrival I met with Patrick Kelley Sr.who
reported he was pulling out of stewartsand saw a girl lignms)walking acrossthe streettexting anda cartumed Rom SouthWilliams striking thegirl walking.
Kelley stated the car bounced her but did not run over her.
I then met with the victim Man mGigann age 13, of Whitehall. SheStatedshewas in the crosswalkwhenshewasstuck by a vehicle. C4ngs was sitting on the
grassnear the roadway being attendedto by EMS. I observedher to haveabrasionsfo her arm and lowerles. Shewas comp!9 of ankle, foot andlower log
pain.
Iinterviewed John Bolton who advisedhe observedthe incident. He statedthefemale (Qgue) was looking ather phonewhile crossing the road.He statedher
headwas down and that the car turned from South Williams andstruck her. He stated it appearedC eversaw the car coming.
I finally interviewed the operator Etnily Smith, age 18.Smith statedshe was turning left from SouthWil1lamsonto Poultney street.Shestatedshetumedandnever
saw anyone in the crosswalk. Smith statedall of a suddenshewas there (agme) and shecould not avoid hitting her.
C al%;randparentsarrived and transportedher to the hospital for evaluation. The injuries did not appearlife (hreating.Smith motherarrived and gaveheraride
home. The car was left and Smith statedthey would pick it up later.
Based on investigation I find inattention on bot
Preview
FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021 EXHIBIT B FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021 83/09/Z1 13:19 M6 AI lstate_RFC -> 518 587 BZ69 Al1state Insurance C Page 883 RELEASE OF ALL CLAIMS CLAIM # Z8322330 This Indenture Witnesseth that, in consideration of the sum of One hundred thousand dollars(S*Settlement 100,000), receipt whereof is hereby acknowledged, for myself and for my heirs, personal representatives and assigns, I do hereby release and forever discharge Arthur R Smith, Julie A Smith, Emily Smith, Encompass Home and Auto Insurance Company and any other person, finn or corporation charged or chargeable with responsibility or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, arising from any act or occurrence up to the present time and particularly on account of all personal injury, disability, property damages, loss or damages of any kind already sustained or that I may hereafter sustain in consequence of an accident that occurred on or about the 24th day of June, 2020, at or near Pultney St, Whitehall, NY. To procure payment of the said sum, I hereby declare: that I am more than 18 years of age; that no representations about the nature and extent of said injuries, disabilities or damages made by any physician, attorney or agent of any party hereby release, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties release, have induced me to make this settlement; that in determining said sum there has been taken into consideration not only the ascertained injuries, disabilities and damages, but also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. I hereby agree that, as a further consideration and inducement for this compromise settlement, that it shall apply to all unknown and unanticipated injuries and damages resulting from said accident, casualty or event, as well as to those now disclosed. I further understand that I admit no liability of any sort by reason of said accident and that said payments and settlements in compromise is made to terminate further controversy respecting all claims for damages that I have heretofore asserted or that I or my personal representatives might hereafter assert because of said accident. I further understand that such liability as I may or shall have incurred, directly or indirectly, in connection with or for damages arising out of the accident to each person or organization, release and discharge of liability herein, and to any other person or organization, is expressly reserved to each of them, such liability not being waived, agreed upon, discharged nor settled by the release. The undersigned expressly covenants and warrants that all Medicare, Medicare Advantage Organization, Medicare Advantage Plan, and/or Medicaid, hospital, medical provider, health care provider, medical supplier and other medical liens, subrogation rights, rights of payment, rights of reimbursement and claims of any nature whatsoever, arising now or in the future, as a result of health care services provided to the undersigned have been or will be satisfied, settled, compromised byor paid express agreement Medicare, Medicare with Advantage Organization, Medicare Advantage Plan, and/or Medicaid, each insurance carrier and each hospital, health care provider, medical provider or medical supplier by the undersigned prior to final disbursement of the settlement proceeds. The undersigned covenants and warrants that all such claims, liens, payment obligations and assigmnents have beenWsclosed in writing to the parties released prior to settlement. The undersigned agrees to indemnify, defend and hold harmless the parties released for any and all losses, claims, demands or causes of action, and any damages, judgments, fees, expenses, costs (including interest) of any nature whatsoever paid and incurred as a result of any breach of these wan·anties and covenants. The undersigned understands and agrees that . the parties releaseyl have relied on these material representpions as part of the consideration and inducemènt for this settlement. The nudersigned uriderstands and agrees that such liability as he/she may or shall have mcurred, ansing now or in the future, as a result of health care services provided to the undersigned, including any health care lien, statutory or otherwise, is expressly reserved to each and every health care provider or payor based on such services, such Z8322330 SE Initials FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021 83 / B9/ 21 13t28187 A IIstate-RFC 4 518 587 8269 91Istate Insurance C Page 884 liability not being in any way waived, agreed apon, discharged, released or settled or impacted in anyway, by this rdease. This specificany includes, but is not limited to, any fiability the ondersigned rñay have to any hospital, health care provider, medical provider, medical agpplier, Medicar4 Medicare Adfantage Organization, Medicare Advantage Plan, and/or Medicaid. Jf any subrogation claimsdiens or rights to payment of any kind against these settlement proceeds do in fact exist, the undersigned shall distribute these fúnds in accord with such elaims, liens or rights to payment (or shalf direct his/her attomey to do so) The undersigned agrees tö indemnify, defend and hold harmless the parties released forany and alhosses, claims, dõmands or causes of action, and any damages, judgments, feesa expenses, costs (including interest) of any nature what«áever paid and incurred as a resuh of any breach of these lagreements and covenants, The undersigned understands and agrees that the parties released have relied on these materialrepresentations as piart of the consideration and inducement for this settlement. Any person who knowingly and withintent to defraud any insurance company or other person files an application for insurance or statement of gIaim containing any materially falsedaferisationror conceals for the purpose of misleading, informAtion concerning any factniaterial thereto, commitsy frandolent insurance act, which is a crime, and shaH also be subje¢tto a civilpenalty not to exceed flye t pugM4ollars andthe stated value of the claim for each such violatfâñ. Aute Claims Only:sny person who knowingly makes or knowingly assists, abees, solicitt er conspires with another to make$ false report of the theft, destructionatantage Weeritersion of any motor vehicle fo a law enforcement.agency, the department of aptor rehkl6s Wan insurghee company, enanüts a fraudulere insurahee act, which b a wimef and shall also be aub ect to a civil pe¼ielty not to exceedl ive thousand dolla&add the value of the subject motor vehlete or stated (CAUTIQN-READ BEFORR SIGNINGy SIGNED AND 5FALED THIS AT UF , S gn ture Witnessed y: COUNTY OF b004 6Yi On this day of , before nie personally appear 03_, to me known to Be the pgrsoris he executed the foregoing instrunient, and acknow edged that they executed thecsame as their fred act add deed My coranzisslon ex ires 21a3 5tia lhibirlaw- NoWFPublié HOLLY A. RABlDEAU Notary Public - State of New York No. 01RA6161693 Qualified in Essex County My Commission Expires Feb. 26, 20 GIINF009 Z8322s30 SE Initials FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 NYSCEF DOC. NO. 83/89/21 4 13:19: 46 AI Istate RFC -> 518 587 8269 Al 1state RECEIVED Insurance NYSCEF: 04/12/2021 C Page 883 RELEASE OF ALL CLAIMS CLAIM # Z8322330 This Indenture Witnesseth that, in consideration of the sum of One hundred thousand dollars ($*Settlement 100,000), receipt whereof is hereby acknowledged, for myself and for my heirs, personal representatives and assigns, I do hereby release and forever discharge Arthur R Smith, Julie A Smith, Emily Smith, Encompass Home and Auto Insurance Company and any other person, firm or corporation charged or chargeable with responsibility or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, arising from any act or occurrence up to the present time and particularly on account of all personal injury, disability, property damages, loss or damages of any kind already sustained or that I may hereafter sustain in consequence of an accident that occurred on or about the 24th day of June, 2020, at or near Pultney St, Whitehall, NY. To procure payment of the said sum, I hereby declare: that I am more than 18 years of age, that no representations about the nature and extent of said injuries, disabilities or damages made by any physician, attorney or agent of any party hereby release, nor any representations regarding the nature liability and extent of legal or financial responsibility of any of the parties release, have induced me to make this settlement, that in determining said sum there has been taken into consideration not only the ascertained injuries, disabilities and damages, but also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. I hereby agree that, as a fm-ther consideration and inducement for this compromise settlement, that it shall apply to all unknown and unanticipated injuries and damages resulting from said accident, casualty or event, as well as to those now disclosed. I further understand that I admit no liability of any sort by reason of said accident and that said payments and settlements in compromise is made to terminate further controversy respecting all claims for damages that I have heretofore asserted or that I or my personal representatives might hereafter assert because of said accident. I fmther understand that such liability as I may or shall have incurred, directly or indirectly, in connection with or for damages arising out of the accident to each person or organization, release and discharge of liability herein, and to any other person or organization, is expressly reserved to each of them, such liability not being waived, agreed upon, discharged nor settled by the release. The undersigned expressly covenants and warrants that all Medicare, Medicare Advantage Organization, Medicare Advantage Plan, and/or Medicaid, hospital, medical provider, health care provider, medical supplier and other medical liens, subrogation rights, rights of payment, rights of reimbursement and claims of any nature whatsoever, arising now or in the future, as a result of health care services provided to the undersigned have been or will be satisfied, settled, compromised or paid by express agreement with Medicare, Medicare Advantage Organization, Medicare Advantage Plan, and/or Medicaid, each carrier insurance hospital, health care and each provider, medical provider or medical supplier by the undersigned prior to final disbursement of the settlement proceeds. The undersigned covenants and warrants that all such claims, liens, payment obligations and assigmnents have been disclosed in writing to the parties released prior to settlement. The undersigned agrees to indemnify, defend and hold harmless the parties released for any and all losses, claims, demands or causes of action, and any damages, judgments, fees, expenses, costs (including interest) of any nature whatsoever paid and incurred as a result of any breach of these warranties and covenants. The undersigned understands and agrees that the parties released have relied on these material representations as part of the consideration and inducement for this settlement. The undersigned understands and agrees that such liability as he/she may or shall have incurred, arising now or in the future, as a result of health care services provided to the undersigned, including any health care lien, statutory or otherwise, is expressly reserved to each and every health care provider or payor based on such services, such Z8322330 SE Initials FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 NYSCEF DOC. NO. 83/09/21 4 13:Z8:07 Al Istate-RFC -> 518 587 8Z69 A1Istate RECEIVED Insurance NYSCEF: 04/12/2021 C Page 884 liability not in any way waived, being agreed upon, discharged, released or settled or impacted in anyway, by this release. This specifically includes, but is not limited to, any liability the undersigned may have to any hospital, health care provider, medical provider, medical supplier, Medicare, Medicare Advantage Organization, Medicare Advantage Plan, and/or Medicaid. If any subrogation claims, liens or rights to payment of any kind against these settlement proceeds do in fact exist, the undersigned shall distribute these funds in accord with such claims, liens or rights to payment (or shall direct his/her attorney to do so). The undersigned agrees to indemnify, defend and hold hannless the parties released for any and all losses, claims, demands or causes of action, and any damages, judgments, fees, expenses, costs(including interest) of any nature whatsoever paid and incurred as a result of any breach of these agreements and covenants. The undersigned understands and agrees that the parties released have relied on these material representations as part of the consideration and inducement for this settlement. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statemcat of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a frauda:cat insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thensand dollars and the stated value of the claim for each such violation. Auto Claims Only: Any person who knewingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance cc:ni-any, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thensand dollars and the value of the subject motor vehicle or stated. (CAUTION-READ BEFORE SIGNING) SIGNED AND SEALED THIS DAY OF At r , O Signature O (Seal) o Name printed Witnessed by: STATE OF Swa (K y COUNTY OF & On this day of , 202J , before me personally appeared (bfCGdon Q 0 g, , to me known to be the persons who executed the foregoing instrument, and acknowledged that they executed the same as their free act and deed. My commission expires CXc a9 a3 myÅ4LÊ AÅ sQ{ Notary Public KlMBERLY A. WILSON NotaryP ublic State of New York No. 01Wl5079583 Qualified in Saratoga Cot nty Comrnission Expires_ _qi 3 GENF009 Z8322330 SE Initials FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 P NYSCEF:F-669 07-14-'20 08:47 FROM-whitehall PD 5184993570 T-447 P0005/0005 NYSCEF DOC. NO. 4 RECEIVED 04/12/2021 '°°ª'°°°ªª POUICEACÖÏDEN TREPORT 7 MV-104A (6/04) RMOYGTRTEUER DMV COPY AnoldentDate .__ Dayof Week MilharyTime No.af No.InjuredKilled NotInvestiOBIGd atScGne LeftScene PolicePhotos M as Y Veh as ---------------------------- g AccidentReepnehucted Û Yes 0 VEHICLE 1 O VEHICLE2 D BlCYCLIST & PEDESTRIAN O OTHERPEDESTRIAN VEHCLE1 - DFNer Stateof Uc. VEHICLE 2- Onver StateofUc. 2 LicenseIDNumber I.icense10Number 21 DdverName-exactly DriverName- exactly asDrintedon\lconso asprintedonlicense Address Apt.No. Address Apt No, 8 S Unifcensed No.of blic Sex Unlicensed No.of Public Occupants roperty r Occupants Pmperty amaacd D Damaged -- - ah N me-exactlyas p iod roofst ti Sex asprintedonregistration Name-exactly Sex Month Day Year ' Month Day Year Address( Number& Street) Apt.No. Her. Released Address(/ncludeNumber& Street) Apt.No. Haz. Released 4 Mat Mat. Cityo s city orTown State Zfp Cods 24 S Reo. V aYear& Make VeNcle PlateNumber StateofRs0. VehicleYear& Make VehicleType na.Code cket/Arrest 'ficket/Arrest Number(s) Numoer(s) Violation Violellon Section(s) Section(s) Check If involved vehicle is: Check II involved vehicle Is: Circle the diagram below that describes the accident, or arawyour own O more than 95 inches wide; O more than 98 Inches wide; diagramin space #9. Number the vehicles. V D more than 34 feet long; V O more than 34 feet long: RightAngle RightTurn HeadOn RearUnd Left m E O operated with an overweight permíl: E O operated with an overweight permit; '4- H O operated With an overdimension permit. H O opersitedwith an ovemi=ndon permit. VEHICLE 1 DAMAGE CODES ( VEHICLE 2 DAMAGE CCDES Sideswi SideswIpe 26 4 LeftTum RightTum. - C 2 c Box 1 - Point of Impact 1 2 (same scuon) (oppoeno direction) . Box 1 - Point of Impact ++ L Box 2- Most Damage L Box 2 - Most Damage 2. Ý•- o a a f n E Enter up to three 3 4 5 E Enter up to three 8 4 g ACCIDENT DIAGRAM more Darnage Codes mate Damage Codes Vehicio Sy Vehicle By Towed: Towed To To VEl-ffCLE DAMAGE CODING: 1-13, SEE DIAGRAM ON RIGHT. 14. UNDERCARRIAGE 17. DEMOLISHED 15. TRAILER 18. NO DAMAGE 28 16. OVERTURNED 19. OTHER Cost of repairs to any one vs hicle will be more than $1000. n ) n n Unknown!Unable to Deterrnine Yes ¤ No Reference Marker Coordinates (if available) P ace Wiiefe A c dent Occurred: . Latitude/Northing: County O City Village O Town of , Roadon whfchaccidentoccurred M (RouteNumberor StreetName) at1) intersectingstreet. . Î , [ - - Longitude/Easting: (RouteNumberorStreetName) DN S or 2) O E O W of I'eet Miles (MUepost RouteNumberorstreet NearestIntemectina Name) Accident Description/0fficer's Notes so c ( 8 9 10 11 12 13 14 15 16 17 BY TO 18 Names of all inv Ived Dateof Death 2nly_ 0 O . .. ..-. V E D Oficed Rank Badge/ID No. NCIC No. Precinct/Pos Station/Beat/ Rev wing Date fime Reviewed and Signature Troop/Zone Sector icer FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 07-14-'20 08:46 FROM-whitehall PD 5184993570 T-447 P0002/0005 F-669 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021 1. Agency 2. piv/Precinct 3. ORI 5. CaseNo, 6. Incident No. VILLAGE OF WHITEHALL . NY0572800 20-31748 31748 7,8,9.Date Reported (Day, Date, Time) 10,1012, Occurred On/Froin (Day Date Time) 13,14,I5. Occurred To (Day, Date, Time) WEDNESDAY 06/24/2020 I8:30 WEDNESDAY 06/24/2020 18:30 16. In cident Type 17. BusinessName ACCIDENT-PERSONAL INJURY 19. Incident Address (Street Name, Bidg. No., fi ii-No-) POULTNEY STREET 20. Ci¼/State/Zip WHITEHALL NEW YORK 12887-0000 21. Location Code (TSLED) 23. No. of Victims 24. No.otSuspects 26, Victim also Cc:::p!±:::t? WHITEHALL VILLAGB 5828 0 0 No Location Type ASSOCIATEDPERSONS VEHICLE SMITH, EMILY A egfR/2001 RABBAAAWN1BlP OPERATOR WITNESS KELLEY, PATRICK M SR 5E8/1966 (518 WH(TEHALL NY 12887 WITNESS BOLTON, JONATHON B /1985 (518) BLDO 128APT C WH1TEHALL NY 12887 VICTIM .M /2007 WHITEHALL NY VICTIM Name 27. DOB 28. Age 29. Cender 30 Race 31. Ethnicity 32.Handicap 33. ResidenceStatus AnggnngnhM /2007 13 PEMALE WHITE NOTHISPANIC Victim DID receive i=fo=a:ffo:: on Victim's Rights and Services pursuant to New York State Law O Yes El No VEHICLE 59. Vehicle Status 60. License Plate No. 61. State 62. Exp, Yr. 64. Value OBSERVED FEY5016 NY $0.00 63. Plate Type 65. Year 66. Make 67. Model PASSENGER AUTOMOBILE (kEGULAR PLATES) 2016 HONDA CRV 68.Style 69. VIN 70. Color(s) 71a. Towed By 71b. Towed To 72. Vehicle Notes DAMAGE LEFT FRONT PENDER Page 1 of 2 07/14/2020 07:27:10 FILED: WASHINGTON COUNTY CLERK 04/12/2021 09:28 AM INDEX NO. EC2021-32724 07-14-'20 08:46 FROM-whitehall PD 5184993570 T-447 P0003/0005 F-669 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 04/12/2021 NARRATIVE Date of Action Date Written Officer Name & Rank 06/24/2020 06/24/2020 HUMPHRiBS, WILLIAM(PATROLMAN) Narrative On todays dateI respondedto a one car vs. personMVA at the intersectionof Poultney and SouthWilliams streets.Upon arrival I met with Patrick Kelley Sr.who reported he was pulling out of stewartsand saw a girl lignms)walking acrossthe streettexting anda cartumed Rom SouthWilliams striking thegirl walking. Kelley stated the car bounced her but did not run over her. I then met with the victim Man mGigann age 13, of Whitehall. SheStatedshewas in the crosswalkwhenshewasstuck by a vehicle. C4ngs was sitting on the grassnear the roadway being attendedto by EMS. I observedher to haveabrasionsfo her arm and lowerles. Shewas comp!9 of ankle, foot andlower log pain. Iinterviewed John Bolton who advisedhe observedthe incident. He statedthefemale (Qgue) was looking ather phonewhile crossing the road.He statedher headwas down and that the car turned from South Williams andstruck her. He stated it appearedC eversaw the car coming. I finally interviewed the operator Etnily Smith, age 18.Smith statedshe was turning left from SouthWil1lamsonto Poultney street.Shestatedshetumedandnever saw anyone in the crosswalk. Smith statedall of a suddenshewas there (agme) and shecould not avoid hitting her. C al%;randparentsarrived and transportedher to the hospital for evaluation. The injuries did not appearlife (hreating.Smith motherarrived and gaveheraride home. The car was left and Smith statedthey would pick it up later. Based on investigation I find inattention on bot