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THE MARQUART LAW GROUP
22342 Avenida Empresa, Suite 250
Rancho Santa Margarita, CA 92688
Tel: (949) 589-0150
Fax: (949) 589-0160
Jeffrey R. Marquart, Esq. (SBN 142663)
Derek J. VanDeviver, Esq. (SBN 227902)
Attorneys for Plaintiff, JENNIFER JAN JENSEN, by and through her Guardian ad Litem,
JORDAN D. MEIER
SUPERIOR COURT OF THE STATE OF CALIFORNIA
COUNTY OF SANTA BARBARA, SOUTH DIVISION
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12 JENNIFER JAN JENSEN, by and through ) CASE NO. 19CV05988
her Guardian ad Litem, JORDAN D.
13 MEIER, Assigned for all purposes:
Honorable Donna Geck
14 Plaintiff, Department SB4
15 NOTICE OF LODGMENT:
V. PUBLIC-REDACTS MATERIALS
16
CITY OF SAN BUENAVENTURA,
17 REBECCA KOFMAN, DEREK
DONSWYK, CORPAT, INC., EAN Action Filed: November 8, 2019
18 HOLDINGS, LLC, DERRICK JOHN Trial Date: Vacated
THOMPSON, JUSTYN DESEAN
19 SANDERS, DIAMONTE MARKEL Hearing
HENDERSON and DOES | through 100, Date: March 5, 2024
20 inclusive, Time: 8:30 a.m.
21 Defendants.
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23 Plaintiff, JENNIFER JAN JENSEN, by and through her Guardian ad Litem, JORDAN
24 D. MEIER, hereby submit this Notice of Lodgment: Public-Redacts Materials From
25 Conditionally Sealed Record.
26 The following documents are attached:
27 //
28 //
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NOTICE OF LODGMENT: PUBLIC-REDACTS MATERIALS FROM CONDITIONALLY SEALED
RECORD
EXHIBIT A: Petition for Compromise of Claim
EXHIBIT B: Order Approving Petition.
DATED: March 4, 2024 THE MARQUART LAW GROUP
By
JEFFREY\R. MARQUART
DEREK J. VANDEVIVER
Attorneys for Plaintiff,
JENNIFER JAN JENSEN by and
through her Guardian ad Litem,
JORDAN D. MEIER
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NOTICE OF LODGMENT: PUBLIC-REDACTS MATERIALS FROM CONDITIONALLY SEALED
RECORD
EXHIBIT A
MC-350
ATTORNEY OR PARTY WITHOUT ATTORNEY ‘STATE BAR NUMBER: FOR COURT USE ONLY
name: Jeffrey R. Marquart 142663
rirmname: The Marquart Law Group
street appress: 22342 Avenida Empresa, Suite 250
ety: Rancho Santa Margarita state: CA ap cove: 92688
reternoneno: (949) 589-0150 raxno: (949) 589-0160
EvalLavoress: JMarquart@marquartlawgroup.com
ATTORNEY FoR Name): Jennifer Jan Jensen
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Santa Barbara
‘STREET ADDRESS: 1100 Anacapa Street
MAILING ADDRESS:
CITY AND ZIP CODE: Santa Barbara, CA 93121
BRANCH NAME: Anacapa
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
HEARING DATE.
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
3/5/2024
OR ACTION OR DISPOSITION OF PROCEEDS OF
DEPT. TIME:
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
SB4 8:30 am
NOTICE TO PETITIONER
Except as noted below, you must use this form to request court approval of (1) the compromise of a minor's disputed claim,
(2) the compromise or settlement of a pending action or proceeding to which a minor or a person with a disability (including a
conservatee) is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See
Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.)
Both you and the minor or person with a disability must attend the hearing on this petition unless the court dispenses with a personal
appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and the
presentation of other evidence relating to the claim and the nature and extent of the injury, care, treatment, and hospitalization.
The court has authority to consider a request for expedited approval without a hearing of the compromise of certain claims or actions
or the disposition of the proceeds of certain judgments. To determine whether your claim, action, or judgment qualifies, see Cal. Rules
of Court, rule 7.950.5. If you want to request expedited consideration, you must use form MC-350EX.
Petitioner (name or pseudonym’): Jordan D. Meier
is the (check all boxes that apply): () Parent [Q) Guardian ad litem* () Guardian () Conservator
[) Other (specify relationship): Son
of the claimant identified in item 2. (*Petitioner
may appear under a pseudonym only if appointed as guardian ad litem under that
pseudonym. (See Code Civ. Proc., § 372.5.))
Claimant (name): Jennifer Jan Jensen
a Address
b. Date of bit Minor or [&) Person with a disability
(If the claimar int is an adult wit a disability who (1) has Capacity to consent to the order requested and (2) does not have a
conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.))
e. [Q) Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or judgment.
f. [4] Does not have a conservator of the estate.
Claim The claim of the minor or adult person with a disability (check one):
a. [CQ] Isnot the subject of a pending action or proceeding. (Complete items 4-23.)
b. [XJ Is the subject of a pending action or proceeding that will be compromised or settled without a trial. (Complete items 4-23.)
Name of court: Santa Barbara Superior Court
Case no. 19CV05988 Trial date: Vacated
c. [2] Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the
defendants named below in the amount (excluding interest and costs) of (specify total): $
Defendants (names):
(2) Additional defendants listed on Attachment 3
(2) The judgment was filed on (date):
(Attach a copy of the (proposed) judgment as Attachment 3c and complete items 12-23.)
Page 1 of 10
Form Adopted for Alernative Mandatory Use PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Code of Civil Procedure, § 372,
Instead of Form MC-35¢ Probate Code, §§ 35 00-2613;
Judicial Council of California OR ACTION OR DISPOSITION OF PROCEEDS OF Cal Rules of Cour ues 2.138
-350 [Rev. January 1, 201] -7 952
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www. courts.ca.gov
CEB
cebcom
Essential
‘orms”
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
4 Incident or accident The incident or accident occurred as follows:
a Date and time: September 4, 2018 4:00 pm
b. Place: Channel Drive and Butterfly Lane, Santa Barbara
c. Persons involved (names): Plaintiff Jennifer Jan Jensen; Defendants Derrick John Thompson, Justyn Desean Sanders, Diamonte
Markel Henderson, City of San Buenaventura Police Officers Rebecca Kofman and Derek Donswyk
(2) Continued on Attachment 4.
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe what happened):
Jennifer Jan Jensen, a pedestrian, was hit by a vehicle operated by defendant Derek John Thompson. The vehicle
was being chased by City of San Buenaventura Police Officers Rebecca Kofman and Derek Donswyk.
(2) Continued on Attachment 5.
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
See attached
[Q) Continued on Attachment 6.
Treatment
The claimant received the following care and treatment for the injuries described in item 6 (describe):
Plaintiff treated for approximately 30 days in Cottage Hospital before being transportec
injuries na
(2) Continued on Attachment 7.
Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries
ora prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as
Attachment 8. A new reportis not necessary if a previous report accurately describes the claimant's current condition.)
a. [2] The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent
injuries.
b. [2] The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms):
() Continued on Attachment 8b.
c. [X] The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms):
ee
() Continued on Attachment 8c.
™ TREY TenuaryT mT PETHHON
COMPROMSE
FOR APPROVAL OF GF ELATIT Page Zor Ty
OR ACTION OR DISPOSITION OF PROCEEDS OF
CB Essential
cebcom *{2\Forms- JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY,
Plaintiff
MC-350
CASE NAME CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
9. [(&) Petitioner has madea careful and di nt inquiry and investigation into the facts and circumstances of the incident
or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Pt joner understands that if the compromise proposed in this petition is
approved by the court and consummated, the claimant will never be able to recover any more compensation from the
settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear.
10. Amount and terms of settlement
To settle the claim in item 3a or 3b, the defendants named below have offered to pay the following amounts 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):
._
Defendants (names) Amounts
"a
City of San Buenaventura
Defendants Henderson, Thompson and Sanders
() Defendants and amounts offered continued on Attachment 10b.
The terms of settlement are as follows (if the settlement is to be paid in installments, both the total amount and the present value
of the settlement must be included):
This matter was mediated before R.A. Carrington of Carrington Lindenauer on January 3, 2024. After
negotiations with the administrator for the ERISA lien were concluded, the final settlement agreement was
endorsed on or about January 30, 2024. All settlement funds have been paid and have been deposited in
Plaintiff's counsel's trust account. The matter has been dismissed, but approval of the settlement is requested by
the parties. The settlement from Defendants Henderson, Thompson and Sanders represents their
policy limits.
(2) Continued on Attachment 10c.
11 Settlement payments to others
a [Q]No defendant named in item 10b 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. ()7o settle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants
named in item 10b have also offered to pay money to a person or persons other than claimant.
(1) The total amount offered by all defendants to others (specify): $
(2) Petitioner _[.]does not have (has a claim against the recovery of the claimant (other than for
reimbursement of fees or expenses paid by petitioner and listed under item 14)
(If you answered “has,” explain in Attachment 11b(2) the circumstances and the effect your claim has on the proposed
compromise of the claim described in this petition.)
(3) Petitioner [Jis not Cis a plaintiff in the same action with the claimant.
(If you answered "is," explain in Attachment 11b(3) the circumstances and the effect your claim and its disposition has on
the proposed compromise of the claim or action described in this petition.)
(4) (2) Petitioner would receive money under the proposed settlement.
(5) The settlement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
() Additional plaintiffs or claimants and amounts are listed on Attachment 11b(5)
(6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named
above are specified in Attachment 11b(6).
WC-250 (Rev. January 7, 2027] Page
3 of 10
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
CEB Essential
EJF
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
12. The claimant's medical expenses—including medical expenses paid by petitioner, Medicare, Medi-Cal, and private
insurers—to be paid or reimbursed from proceeds of settlement or judgment
a, Totals
(1) Total medical expenses before any reductions:
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($
(3) Total of negotiated, contractual, or statutory reductions, if any: $
(4) Total medical expenses to be paid or reimbursed from the proceeds:
(5) Total amount of statutory or contractual liens, if any:
Medical expenses were paid and are to be reimbursed from proceeds as follows:
(1) (2) Paid by petitioner in the amount of:
(2) [(K) Paid by private health insurance or a self-funded plan under:
(a) [.} An Employee Retirement Income Security Act (ERISA) insured plan.
(b) KX An ERISA self-funded plan
(c) LQ A Non-ERISA insured plan.
(d) LX) A Non-ERISA self-funded plan
(e) Amount paid by plan $
(f) Amount of reimbursement to the plan from proceeds of settlement o1
(i) (-JNo reimbursement is requested by the plan.
(i) Reimbursement is to be made to the plan, and
(A) Cy there is a contractual reduction of: $ )
(8) Kythere is a negotiated reduction of.
(C) LAYNo reduction has been agreed to,
gs —
for a total reimbursement to the plan, in full satisfaction of its lien rights, in the amount of.
° ___
(3) [2] Paid by Medicare in the amount of: $
less the statutory reduction in the amount of: ($ )
for a total reimbursement to Medicare in the amount of. 0.00
(Attach a copy of the final Medicare demand letter or letter agreement as Attachment 12b(3).)
(4) [2] Paid by Medi-Cal in the amount of: $
(a) ) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code,
§ 14124.73.) A copy of the notice and proof of delivery:
(dis attached () was filed in this case on (date):
(b) (2) Notice of this claim or action has not been given to the Director of Health Care Services. (Explain why notice has
not been given in Attachment 12b(4)(b).)
(c) C.) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of:
$
(Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 12b(4)(c).)
(d) (.) Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and
(check one):
() (2) Is filing a motion seeking a reduction of the lien concurrently with this petition
(i) (Requests that the court reserve jurisdiction over this issue.
The amount of the lien in dispute is: $
(5) (a) (i) Gy There are no statutory or contractual liens for payment of claimant's medical expenses.
(ii) (2) There are one or more statutory or contractual liens of medical service providers for payment of claimant's
medical expenses. The total amount claimed under these liens is: $
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $
(Provide requested information for each lienholder and other specified medical service providers on next page.)
Wic-250 (Rev. January 1, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page 40f 10
@ By m
Essential
2\Forms™
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
12. Claimant's medical expenses (continued)
b. (5) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or
any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and
the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows:
(i) (A) Provider (name):
(B) Address:
(C) Amount charged:
(D) Amount paid (whether or not by insurance) &
(E) Negotiated reduction, if any: $
(F) Amount to be paid from proceeds of settlement or judgment: 0.00
ii) (A) Provider (name):
(B) Address:
(C) Amount charged:
(D) Amount paid (whether or not by insurance) s
(E) Negotiated reduction, if any: ($
(F) Amount to be paid from proceeds of settlement or judgment: 0.00
(iii) (A) Provider (name):
(B) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance) ( )
(E) Negotiated reduction, if any: $ )
(F) Amount to be paid from proceeds of settlement or judgment: $ 0.00
(2) Continued on Attachment 12b(5). (Provide information about additional providers in the above format, including
providers paid or to be paid by petitioner, for which payment reimbursement is requested in item 12b(1), above.
You may use form MC-350(A-12b(5)) for this purpose.)
13. Claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment
a. Total amount of attorney's fees for which court approval is requested $
——_—
(If fees are requested, attach as Attachment 13a a declaration from the attorney explaining the basis for the request, including a :
discussion of applicable factors listedin rule 7.955(b) of the Cal. Rules of Court. Respond to item 17a(2) on page 7 and attach a
copy of any written attorney fee agreement as Attachment 17a.)
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 out of claimant's share of the proceeds of the settlement or judgment:
Items Payees (names) Amounts
Costs
[&) Continued on Attachment 13b.
WiC-250 (Rev. January 7, 2027) PETIT
Total: a P: age
5 of 10,
gE Essential
‘orms”
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
14. Reimbursement of fees and expenses paid by petitioner
a [K) Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested.
b. [] Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's fees and expenses for which
reimbursement is requested.
(1) [J Medical expenses listed in item 12 $
(2) [2] Attorney's fees included in the total fee amount shown in item 13a $
(3) [) Other expenses included in the total shown in item 13b: $
Total $ 0.00
(Attach proofs of the fees and expenses incurred and the payments made or obligations to pay incurred, e.g., bills or invoices,
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
15. Net balance of proceeds for the claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the claimant
after payment of all requested fees and expenses is:
S a.
___
16. SUMMARY
a Gross amount of proceeds of settlement or judgment: $
b. Medical expenses to be paid from proceeds of settlement
or judgment:
Attorney's fees to be paid from proceeds of settlement or
judgment: $
Expenses (other than medical) to be paid from proceeds
of settlement or judgment: $
Total of fees and expenses to be paid from proceeds of settlement or
judgment (add (b), (c), and (d)):
Balance of proceeds of settlement or judgment available for claimant
($ a
after payment of all fees and expenses (subtract (e) from (a)):
S
Wic-250 (Rev. January 1, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page
6 of 10
OR ACTION OR DISPOSITION OF PROCEEDS OF
CEB | Essential
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
cebcom|}fe) Forms"
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
17. Information about attorney representing or assisting petitioner
a (1) () Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with
respect to the claim asserted. (Skip the rest of item 17 and
go to item 18.)
2) [({) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim
asserted. Petitioner and the attorney [J donot (Kido have an agreement for services provided in
connection with the claim giving rise to this petition.
(If you answered “do,” attach a copy of the agreement as Attachment 17a, and complete items 17b-17f.)
The attorney who has represented or assisted petitioner is (name): Jeffrey R. Marquart
(1) State Bar number: 142663
(2) Lawfirm: The Marquart Law Group
(3) Address: 22342 Avenida Empresa, Suite 250
Rancho Santa Margarita, CA 92688
(4) Telephone number: (949) 589-0150 (5) Email: jmarquart@marquartlawgroup.com
The attorney (oy has not qhas received 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. (/f you answered “has," identify the
person who paid the fees or other compensation, the amounts paid, and the dates of payment):
From whom (names) Amounts Dates
i ma
Fees associated with Plaintiff's Underinsured Motorist claim. )
Costs paid from Plaintiff's Underinsured Motorist claim
(Continued on Attachment 17c.
The attorney [X]did not [-Jdid become concerned with this matter, directly or indirectly, at the instance of a party
against whom the claim is asserted or a party's insurance carrier. (If you answered “did,” explain the circumstances in
Attachment 17d.)
The attorney [Qjis not Cis representing or employed by any other party or any insurance carrier involved in the
matter. (If you answered ‘is,” identify the party or carrier and explain the relationship in Attachment 17e.)
The attorney [X]Jdoesnot [J does expect 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 “does,”
identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment):
From whom (names) Amounts Expected dates
() Continued on Attachment 17f.
Wic-250 (Rev. January 1, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page?
of 10
OR ACTION OR DISPOSITION OF PROCEEDS OF
CEB
cebcom
Essential
{2\Forms” JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
18. Disposition of balance for claimant (check either a or b, then check each option requested and enter amount(s)):
a. [L] 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.
(1) (2) Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the
guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(1).
(2) [CQ]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 18a(1) in insured accounts in one or more financial institutions in this state or with a trust company, subject to
withdrawal only on authorization of the court. The money or other property and the name, branch, and address of
each financial institution or trust company are specified in Attachment 18a(2).
(3) [2] 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 ail that apply):
@ Cis to be deposited in insured accounts in one or more financial institutions in this state,
subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are
specified in Attachment 18a(3)(a)
) CVs to be invested in a single-premium deferred annuity subject to withdrawal only on
authorization of the court. The terms and conditions of the annuity are specified in Attachment 18a(3)(b)
© CIs to 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 18a(3)(c)
@) Cas to be transferred to the trustee of a trust that is either created by or approved in the order
approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of
age and contains all other terms and conditions determined to be necessary by the court to protect the minor's
interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 18a(3)
(d)
[JA copy of the (proposed) judgment is attached as Attachment 3c.
ec) CVs to be transferred to the trustee of a special needs trust established under Probate Code
section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special
needs trust and the property to be transferred are specified in Attachment 18a(3)(e).
b. [4] There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the
disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested):
(1) (2) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed
and $ of money or other property or both be paid or delivered to the person so appointed. The
money or other property are specified in Attachment 18b(1)
2) Cis be deposited in insured accounts in one or more financial institutions in this state, subject to
withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in
Attachment 18b(2)
(3) Cis be invested in a single-premium deferred annuity, subject to withdrawal only on authorization
of the court. The terms and conditions of the annuity are specified in Attachment 18b(3).
(4) Cis be paid or transferred to the trustee of a special needs trust established under Probate Code
section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs
trust and the money or other property to be paid or transferred are specified in Attachment 18b(4)
(5) Cis be paid or delivered to a parent of the minor, without bond, on the terms and under the
conditions specified in Probate Code sections 3401-3402. The name and address of the parent and the money or
other property to be delivered are specified in Attachment 18b(5). (Value of minor's entire estate, including the money
or property to be delivered, must not exceed $5,000.)
©) Cis 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 18b(6).
WiC-250 (Rev. January 7, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page
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OR ACTION OR DISPOSITION OF PROCEEDS OF
CEB
cebcom
Essential
2\Forms: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
Plaintiff
MC-350
CASE NAME: CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
18. Disposition of balance of proceeds of settlement or judgment (continued)
b. [&) There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the
disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested):
@m Os be transferred to the trustee of a trust that is either created by or approved in the order
approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age,
and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests.
The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7).
CJA copy of the (proposed) judgment is attached as Attachment 3c.
@) Cis of money be held on any conditions the court determines are in the best interest of the minor
or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not
exceed $20,000.)
@ Cis of property other than money be held on the conditions that the court determines are in the
best interest of the minor or the adult person with a disability. The proposed conditions and the property are specified
in Attachment 18b(9)
(10) CY $ 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).
(11) Ks
—— be paid or delivered to the adult person with a disability. The money or other property is
specifies fachment 18b(11)
19. [) Statutory liens for special needs trust
Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Probate Code
section 3604, if any, will be satisfied):
(2) Continued on Attachment 19
20. [) Additional orders
Petitioner requests the following additional orders (specify and explain):
(2) Continued on Attachment 20
™ TREY TenuaryT mT PETHHON
COMPROMSE
FOR APPROVAL OF GF ELATIT Pages OFT
q B Es: ao
m 2\Forms-
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY.
Plaintiff
MC-350
CASE CASE NUMBER:
Jensen vs. City of San Buenaventura 19CV05988
21. Cai, the claimant named in item 2, consent to the order or judgment requested in this petition.
(Required if the claimantis an adult with a disability who has the capacity, under Probate Code section 812, to consent to the
order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.))
a
Date: 3/4/2024
Jennifer Jan Jensen
(TYPE OR PRINT NAME OF CLAIMANT)
> (SIGNATURE OF CLAIMANT)
22. Petitioner recommends approval of the proposed compromise, settlement, or disposition of judgment proceeds to the court as fair,
reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise, settlement, or
disposition and make any other orders that are just and reasonable.
23. Number of pages attached: 35
Date: 3/3/2024
Jeffrey R. Marquart
(TYPE OR PRINT NAME OF ATTORNEY)
» Sh (SIGNATURE OF ATTORNEY)
| declare under penalty of perjury under the laws of the State of California that the foregoing information on this form and all
attachments is true and correct.
Date:
Jordan D. Meier
(TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER)
MC-360 [Rev. January 1, 2021] PETITION FOR APPROVAL OF COMPROMISE OF CLAIM
Preview
THE MARQUART LAW GROUP 22342 Avenida Empresa, Suite 250 Rancho Santa Margarita, CA 92688 Tel: (949) 589-0150 Fax: (949) 589-0160 Jeffrey R. Marquart, Esq. (SBN 142663) Derek J. VanDeviver, Esq. (SBN 227902) Attorneys for Plaintiff, JENNIFER JAN JENSEN, by and through her Guardian ad Litem, JORDAN D. MEIER SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF SANTA BARBARA, SOUTH DIVISION 10 11 12 JENNIFER JAN JENSEN, by and through ) CASE NO. 19CV05988 her Guardian ad Litem, JORDAN D. 13 MEIER, Assigned for all purposes: Honorable Donna Geck 14 Plaintiff, Department SB4 15 NOTICE OF LODGMENT: V. PUBLIC-REDACTS MATERIALS 16 CITY OF SAN BUENAVENTURA, 17 REBECCA KOFMAN, DEREK DONSWYK, CORPAT, INC., EAN Action Filed: November 8, 2019 18 HOLDINGS, LLC, DERRICK JOHN Trial Date: Vacated THOMPSON, JUSTYN DESEAN 19 SANDERS, DIAMONTE MARKEL Hearing HENDERSON and DOES | through 100, Date: March 5, 2024 20 inclusive, Time: 8:30 a.m. 21 Defendants. 22 23 Plaintiff, JENNIFER JAN JENSEN, by and through her Guardian ad Litem, JORDAN 24 D. MEIER, hereby submit this Notice of Lodgment: Public-Redacts Materials From 25 Conditionally Sealed Record. 26 The following documents are attached: 27 // 28 // 1 NOTICE OF LODGMENT: PUBLIC-REDACTS MATERIALS FROM CONDITIONALLY SEALED RECORD EXHIBIT A: Petition for Compromise of Claim EXHIBIT B: Order Approving Petition. DATED: March 4, 2024 THE MARQUART LAW GROUP By JEFFREY\R. MARQUART DEREK J. VANDEVIVER Attorneys for Plaintiff, JENNIFER JAN JENSEN by and through her Guardian ad Litem, JORDAN D. MEIER 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2 NOTICE OF LODGMENT: PUBLIC-REDACTS MATERIALS FROM CONDITIONALLY SEALED RECORD EXHIBIT A MC-350 ATTORNEY OR PARTY WITHOUT ATTORNEY ‘STATE BAR NUMBER: FOR COURT USE ONLY name: Jeffrey R. Marquart 142663 rirmname: The Marquart Law Group street appress: 22342 Avenida Empresa, Suite 250 ety: Rancho Santa Margarita state: CA ap cove: 92688 reternoneno: (949) 589-0150 raxno: (949) 589-0160 EvalLavoress: JMarquart@marquartlawgroup.com ATTORNEY FoR Name): Jennifer Jan Jensen SUPERIOR COURT OF CALIFORNIA, COUNTY OF Santa Barbara ‘STREET ADDRESS: 1100 Anacapa Street MAILING ADDRESS: CITY AND ZIP CODE: Santa Barbara, CA 93121 BRANCH NAME: Anacapa CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 HEARING DATE. PETITION FOR APPROVAL OF COMPROMISE OF CLAIM 3/5/2024 OR ACTION OR DISPOSITION OF PROCEEDS OF DEPT. TIME: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY SB4 8:30 am NOTICE TO PETITIONER Except as noted below, you must use this form to request court approval of (1) the compromise of a minor's disputed claim, (2) the compromise or settlement of a pending action or proceeding to which a minor or a person with a disability (including a conservatee) is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) Both you and the minor or person with a disability must attend the hearing on this petition unless the court dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and the presentation of other evidence relating to the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court has authority to consider a request for expedited approval without a hearing of the compromise of certain claims or actions or the disposition of the proceeds of certain judgments. To determine whether your claim, action, or judgment qualifies, see Cal. Rules of Court, rule 7.950.5. If you want to request expedited consideration, you must use form MC-350EX. Petitioner (name or pseudonym’): Jordan D. Meier is the (check all boxes that apply): () Parent [Q) Guardian ad litem* () Guardian () Conservator [) Other (specify relationship): Son of the claimant identified in item 2. (*Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ. Proc., § 372.5.)) Claimant (name): Jennifer Jan Jensen a Address b. Date of bit Minor or [&) Person with a disability (If the claimar int is an adult wit a disability who (1) has Capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.)) e. [Q) Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or judgment. f. [4] Does not have a conservator of the estate. Claim The claim of the minor or adult person with a disability (check one): a. [CQ] Isnot the subject of a pending action or proceeding. (Complete items 4-23.) b. [XJ Is the subject of a pending action or proceeding that will be compromised or settled without a trial. (Complete items 4-23.) Name of court: Santa Barbara Superior Court Case no. 19CV05988 Trial date: Vacated c. [2] Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the defendants named below in the amount (excluding interest and costs) of (specify total): $ Defendants (names): (2) Additional defendants listed on Attachment 3 (2) The judgment was filed on (date): (Attach a copy of the (proposed) judgment as Attachment 3c and complete items 12-23.) Page 1 of 10 Form Adopted for Alernative Mandatory Use PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Code of Civil Procedure, § 372, Instead of Form MC-35¢ Probate Code, §§ 35 00-2613; Judicial Council of California OR ACTION OR DISPOSITION OF PROCEEDS OF Cal Rules of Cour ues 2.138 -350 [Rev. January 1, 201] -7 952 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www. courts.ca.gov CEB cebcom Essential ‘orms” Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 4 Incident or accident The incident or accident occurred as follows: a Date and time: September 4, 2018 4:00 pm b. Place: Channel Drive and Butterfly Lane, Santa Barbara c. Persons involved (names): Plaintiff Jennifer Jan Jensen; Defendants Derrick John Thompson, Justyn Desean Sanders, Diamonte Markel Henderson, City of San Buenaventura Police Officers Rebecca Kofman and Derek Donswyk (2) Continued on Attachment 4. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened): Jennifer Jan Jensen, a pedestrian, was hit by a vehicle operated by defendant Derek John Thompson. The vehicle was being chased by City of San Buenaventura Police Officers Rebecca Kofman and Derek Donswyk. (2) Continued on Attachment 5. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): See attached [Q) Continued on Attachment 6. Treatment The claimant received the following care and treatment for the injuries described in item 6 (describe): Plaintiff treated for approximately 30 days in Cottage Hospital before being transportec injuries na (2) Continued on Attachment 7. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries ora prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 8. A new reportis not necessary if a previous report accurately describes the claimant's current condition.) a. [2] The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent injuries. b. [2] The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): () Continued on Attachment 8b. c. [X] The claimant has not recovered completely from the effects of the injuries described in item 6, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms): ee () Continued on Attachment 8c. ™ TREY TenuaryT mT PETHHON COMPROMSE FOR APPROVAL OF GF ELATIT Page Zor Ty OR ACTION OR DISPOSITION OF PROCEEDS OF CB Essential cebcom *{2\Forms- JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY, Plaintiff MC-350 CASE NAME CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 9. [(&) Petitioner has madea careful and di nt inquiry and investigation into the facts and circumstances of the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Pt joner understands that if the compromise proposed in this petition is approved by the court and consummated, the claimant will never be able to recover any more compensation from the settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear. 10. Amount and terms of settlement To settle the claim in item 3a or 3b, the defendants named below have offered to pay the following amounts 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): ._ Defendants (names) Amounts "a City of San Buenaventura Defendants Henderson, Thompson and Sanders () Defendants and amounts offered continued on Attachment 10b. The terms of settlement are as follows (if the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included): This matter was mediated before R.A. Carrington of Carrington Lindenauer on January 3, 2024. After negotiations with the administrator for the ERISA lien were concluded, the final settlement agreement was endorsed on or about January 30, 2024. All settlement funds have been paid and have been deposited in Plaintiff's counsel's trust account. The matter has been dismissed, but approval of the settlement is requested by the parties. The settlement from Defendants Henderson, Thompson and Sanders represents their policy limits. (2) Continued on Attachment 10c. 11 Settlement payments to others a [Q]No defendant named in item 10b 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. ()7o settle claims arising out of the same incident or accident that resulted in the claimant's injury, one or more defendants named in item 10b have also offered to pay money to a person or persons other than claimant. (1) The total amount offered by all defendants to others (specify): $ (2) Petitioner _[.]does not have (has a claim against the recovery of the claimant (other than for reimbursement of fees or expenses paid by petitioner and listed under item 14) (If you answered “has,” explain in Attachment 11b(2) the circumstances and the effect your claim has on the proposed compromise of the claim described in this petition.) (3) Petitioner [Jis not Cis a plaintiff in the same action with the claimant. (If you answered "is," explain in Attachment 11b(3) the circumstances and the effect your claim and its disposition has on the proposed compromise of the claim or action described in this petition.) (4) (2) Petitioner would receive money under the proposed settlement. (5) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts () Additional plaintiffs or claimants and amounts are listed on Attachment 11b(5) (6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified in Attachment 11b(6). WC-250 (Rev. January 7, 2027] Page 3 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM CEB Essential EJF OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 12. The claimant's medical expenses—including medical expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—to be paid or reimbursed from proceeds of settlement or judgment a, Totals (1) Total medical expenses before any reductions: (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ (3) Total of negotiated, contractual, or statutory reductions, if any: $ (4) Total medical expenses to be paid or reimbursed from the proceeds: (5) Total amount of statutory or contractual liens, if any: Medical expenses were paid and are to be reimbursed from proceeds as follows: (1) (2) Paid by petitioner in the amount of: (2) [(K) Paid by private health insurance or a self-funded plan under: (a) [.} An Employee Retirement Income Security Act (ERISA) insured plan. (b) KX An ERISA self-funded plan (c) LQ A Non-ERISA insured plan. (d) LX) A Non-ERISA self-funded plan (e) Amount paid by plan $ (f) Amount of reimbursement to the plan from proceeds of settlement o1 (i) (-JNo reimbursement is requested by the plan. (i) Reimbursement is to be made to the plan, and (A) Cy there is a contractual reduction of: $ ) (8) Kythere is a negotiated reduction of. (C) LAYNo reduction has been agreed to, gs — for a total reimbursement to the plan, in full satisfaction of its lien rights, in the amount of. ° ___ (3) [2] Paid by Medicare in the amount of: $ less the statutory reduction in the amount of: ($ ) for a total reimbursement to Medicare in the amount of. 0.00 (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 12b(3).) (4) [2] Paid by Medi-Cal in the amount of: $ (a) ) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.) A copy of the notice and proof of delivery: (dis attached () was filed in this case on (date): (b) (2) Notice of this claim or action has not been given to the Director of Health Care Services. (Explain why notice has not been given in Attachment 12b(4)(b).) (c) C.) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 12b(4)(c).) (d) (.) Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and Institutions Code section 14124.76 and (check one): () (2) Is filing a motion seeking a reduction of the lien concurrently with this petition (i) (Requests that the court reserve jurisdiction over this issue. The amount of the lien in dispute is: $ (5) (a) (i) Gy There are no statutory or contractual liens for payment of claimant's medical expenses. (ii) (2) There are one or more statutory or contractual liens of medical service providers for payment of claimant's medical expenses. The total amount claimed under these liens is: $ In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ (Provide requested information for each lienholder and other specified medical service providers on next page.) Wic-250 (Rev. January 1, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page 40f 10 @ By m Essential 2\Forms™ OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 12. Claimant's medical expenses (continued) b. (5) (b) The name of each medical service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or will be paid from the proceeds) by petitioner, for which payment petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and the amount to be paid from the proceeds of the settlement or judgment to each provider are as follows: (i) (A) Provider (name): (B) Address: (C) Amount charged: (D) Amount paid (whether or not by insurance) & (E) Negotiated reduction, if any: $ (F) Amount to be paid from proceeds of settlement or judgment: 0.00 ii) (A) Provider (name): (B) Address: (C) Amount charged: (D) Amount paid (whether or not by insurance) s (E) Negotiated reduction, if any: ($ (F) Amount to be paid from proceeds of settlement or judgment: 0.00 (iii) (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance) ( ) (E) Negotiated reduction, if any: $ ) (F) Amount to be paid from proceeds of settlement or judgment: $ 0.00 (2) Continued on Attachment 12b(5). (Provide information about additional providers in the above format, including providers paid or to be paid by petitioner, for which payment reimbursement is requested in item 12b(1), above. You may use form MC-350(A-12b(5)) for this purpose.) 13. Claimant's attorney's fees and all other expenses (except medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner, to be reimbursed from proceeds of settlement or judgment a. Total amount of attorney's fees for which court approval is requested $ ——_— (If fees are requested, attach as Attachment 13a a declaration from the attorney explaining the basis for the request, including a : discussion of applicable factors listedin rule 7.955(b) of the Cal. Rules of Court. Respond to item 17a(2) on page 7 and attach a copy of any written attorney fee agreement as Attachment 17a.) 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 out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts Costs [&) Continued on Attachment 13b. WiC-250 (Rev. January 7, 2027) PETIT Total: a P: age 5 of 10, gE Essential ‘orms” OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 14. Reimbursement of fees and expenses paid by petitioner a [K) Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested. b. [] Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's fees and expenses for which reimbursement is requested. (1) [J Medical expenses listed in item 12 $ (2) [2] Attorney's fees included in the total fee amount shown in item 13a $ (3) [) Other expenses included in the total shown in item 13b: $ Total $ 0.00 (Attach proofs of the fees and expenses incurred and the payments made or obligations to pay incurred, e.g., bills or invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) 15. Net balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the claimant after payment of all requested fees and expenses is: S a. ___ 16. SUMMARY a Gross amount of proceeds of settlement or judgment: $ b. Medical expenses to be paid from proceeds of settlement or judgment: Attorney's fees to be paid from proceeds of settlement or judgment: $ Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ Total of fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): Balance of proceeds of settlement or judgment available for claimant ($ a after payment of all fees and expenses (subtract (e) from (a)): S Wic-250 (Rev. January 1, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page 6 of 10 OR ACTION OR DISPOSITION OF PROCEEDS OF CEB | Essential JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY cebcom|}fe) Forms" Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 17. Information about attorney representing or assisting petitioner a (1) () Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the claim asserted. (Skip the rest of item 17 and go to item 18.) 2) [({) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim asserted. Petitioner and the attorney [J donot (Kido have an agreement for services provided in connection with the claim giving rise to this petition. (If you answered “do,” attach a copy of the agreement as Attachment 17a, and complete items 17b-17f.) The attorney who has represented or assisted petitioner is (name): Jeffrey R. Marquart (1) State Bar number: 142663 (2) Lawfirm: The Marquart Law Group (3) Address: 22342 Avenida Empresa, Suite 250 Rancho Santa Margarita, CA 92688 (4) Telephone number: (949) 589-0150 (5) Email: jmarquart@marquartlawgroup.com The attorney (oy has not qhas received 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. (/f you answered “has," identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment): From whom (names) Amounts Dates i ma Fees associated with Plaintiff's Underinsured Motorist claim. ) Costs paid from Plaintiff's Underinsured Motorist claim (Continued on Attachment 17c. The attorney [X]did not [-Jdid become concerned with this matter, directly or indirectly, at the instance of a party against whom the claim is asserted or a party's insurance carrier. (If you answered “did,” explain the circumstances in Attachment 17d.) The attorney [Qjis not Cis representing or employed by any other party or any insurance carrier involved in the matter. (If you answered ‘is,” identify the party or carrier and explain the relationship in Attachment 17e.) The attorney [X]Jdoesnot [J does expect 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 “does,” identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates of payment): From whom (names) Amounts Expected dates () Continued on Attachment 17f. Wic-250 (Rev. January 1, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page? of 10 OR ACTION OR DISPOSITION OF PROCEEDS OF CEB cebcom Essential {2\Forms” JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 18. Disposition of balance for claimant (check either a or b, then check each option requested and enter amount(s)): a. [L] 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. (1) (2) Petitioner requests that $ of the proceeds in money or other property be paid or delivered to the guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(1). (2) [CQ]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 18a(1) in insured accounts in one or more financial institutions in this state or with a trust company, subject to withdrawal only on authorization of the court. The money or other property and the name, branch, and address of each financial institution or trust company are specified in Attachment 18a(2). (3) [2] 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 ail that apply): @ Cis to be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 18a(3)(a) ) CVs to be invested in a single-premium deferred annuity subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18a(3)(b) © CIs to 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 18a(3)(c) @) Cas to be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 18a(3) (d) [JA copy of the (proposed) judgment is attached as Attachment 3c. ec) CVs to be transferred to the trustee of a special needs trust established under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the property to be transferred are specified in Attachment 18a(3)(e). b. [4] There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (1) (2) A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed and $ of money or other property or both be paid or delivered to the person so appointed. The money or other property are specified in Attachment 18b(1) 2) Cis be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 18b(2) (3) Cis be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18b(3). (4) Cis be paid or transferred to the trustee of a special needs trust established under Probate Code section 3604 for the benefit of the minor or the adult person with a disability. The terms of the proposed special needs trust and the money or other property to be paid or transferred are specified in Attachment 18b(4) (5) Cis be paid or delivered to a parent of the minor, without bond, on the terms and under the conditions specified in Probate Code sections 3401-3402. The name and address of the parent and the money or other property to be delivered are specified in Attachment 18b(5). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) ©) Cis 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 18b(6). WiC-250 (Rev. January 7, 2027) PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page 6 of 10 OR ACTION OR DISPOSITION OF PROCEEDS OF CEB cebcom Essential 2\Forms: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY Plaintiff MC-350 CASE NAME: CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 18. Disposition of balance of proceeds of settlement or judgment (continued) b. [&) There is no guardianship or conservatorship of the estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): @m Os be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age, and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7). CJA copy of the (proposed) judgment is attached as Attachment 3c. @) Cis of money be held on any conditions the court determines are in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amount must not exceed $20,000.) @ Cis of property other than money be held on the conditions that the court determines are in the best interest of the minor or the adult person with a disability. The proposed conditions and the property are specified in Attachment 18b(9) (10) CY $ 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). (11) Ks —— be paid or delivered to the adult person with a disability. The money or other property is specifies fachment 18b(11) 19. [) Statutory liens for special needs trust Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Probate Code section 3604, if any, will be satisfied): (2) Continued on Attachment 19 20. [) Additional orders Petitioner requests the following additional orders (specify and explain): (2) Continued on Attachment 20 ™ TREY TenuaryT mT PETHHON COMPROMSE FOR APPROVAL OF GF ELATIT Pages OFT q B Es: ao m 2\Forms- OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY. Plaintiff MC-350 CASE CASE NUMBER: Jensen vs. City of San Buenaventura 19CV05988 21. Cai, the claimant named in item 2, consent to the order or judgment requested in this petition. (Required if the claimantis an adult with a disability who has the capacity, under Probate Code section 812, to consent to the order or judgment and does not have a conservator of the estate. (See Prob. Code, § 3613.)) a Date: 3/4/2024 Jennifer Jan Jensen (TYPE OR PRINT NAME OF CLAIMANT) > (SIGNATURE OF CLAIMANT) 22. Petitioner recommends approval of the proposed compromise, settlement, or disposition of judgment proceeds to the court as fair, reasonable, and in the best interest of the claimant. Petitioner requests that the court approve this compromise, settlement, or disposition and make any other orders that are just and reasonable. 23. Number of pages attached: 35 Date: 3/3/2024 Jeffrey R. Marquart (TYPE OR PRINT NAME OF ATTORNEY) » Sh (SIGNATURE OF ATTORNEY) | declare under penalty of perjury under the laws of the State of California that the foregoing information on this form and all attachments is true and correct. Date: Jordan D. Meier (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) MC-360 [Rev. January 1, 2021] PETITION FOR APPROVAL OF COMPROMISE OF CLAIM