Preview
DocuSign Envelope ID: 58C9EB64-D28A-4A64-AA21-D9788C215678
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MG-350
ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 397.347 FOR COURT USE ONLY
NAVE: Garratt M. Penney |
FIRM NAME: PENNEY & ASSOCIATES
STREET ADDRESS; {490 Stone Point Drive, Suite 150 Do
cit: Roseville STATE: CA AIP CODE: 956861 |
TELEPHONE NO. 948-786-7662 FAXNO.: 916-786-0144 |
EMAIL ADDRESS: gnenney@penneylawyer.com
ATTORNEY FOR (Went: Mikki Gatimbang ;
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO |
STREET ADDRESS: 40Q County Center, 1st Floor, Room A |
MAILING ADDRESS: ; |
CITY AND ZIP GODE: Redwood City, CA 84063 p |
BRANCH NAME: Southern Branch: Hail of Justice and Records | |
CASE NAME: CASE NUMBER |
Catimbang v. Estella Logarta, at al.
HEARING DATE:
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM fee
OR ACTION OR DISPOSITION OF PROCEEDS OF TE: |
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY prem |
NOTICE TO PETITIONER bo
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 @ minor or a person with 4 disability (including a |
conservates) Is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See |
Gade Giv. 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 PO
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 proceads of certaln judgments. To determing whether your clalm, action, or Judgment qualifies, see Cal. Rules too:
of Court, rule 7,950.5, {f you want to request expedited considaration, you must use form MC-350EX,
1. Petitioner (name or pseudonym*): Miguel Catimbang ‘
is the (check al boxes that apply): = (4¢] Parent (3€] Guardian ad litem* [77] Guardian [7] Conservator
[__] Other (specify relaifonship): :
of the claimant Identified in Item 2. (*Petitfoner may appear undera pseudonym only if appointed as guardian ad litem under that :
pseudonym. (See Code Gly. Proo., § 372.5) Po
2. Claimant (name): Mikkl Catimbang po
a. Addreas: 550 Clark Avenue, Colma, CA 94014
b. Date of birth: 07/27/2008 ’ 9. Age: 15 d. (3¢] Minor or [__] Person with a dlsability |
(if ihe claimant is an adult with a disability who (1) has capacity ta consent to the ordor requested and (2) does not have a :
- conservator of the estate, check a. and f. and ensure that the claimant personally reads and signs lem 21. (Prob. Code, § 3613.) |
e. [|__| Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or Judgment. fo
f, ["] Boes not have a conservator of the estate. —
3, Claim The claim of the minor or adult person with 4 disability (check one):
a. [2] Is not the subject of a pending action or proceeding. (Complete items 4-23.) ,
b, [__] Is the subject of a pending action or proceeding that will ba compromised or settled without a trial. {(Gomplete items 4-23.)
Name of court: i
Case na: Trial date: i,
c. [__] Is the subject of an action or proceeding in which a judgment hag been or will be entered for the claimant against the |
‘ defendants named below In the amount (excluding interest and sosts) of (specify total): $ : an
Defendants {names: o
[_] Additional defendants listed on Attachment 3. |
[___] The judgment was filed on (date):
(Atfach a capy of the (proposed) judgment as Aifachmont 3c and complete items 12-23.) Pago of 40
ARE 1A
A rome Maney Use
Judlefal Counell of Callfomia
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Pacate eo, 43800, 000-0 !
OR ACTION OR DISPOSITION OF PROCEEDS OF Gal. Rules of
Cou, rutes 3,1384, .
MC-380 [Rov, J
mane 1, 2024]
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 7.10, 7,050-7,882
win cours.ca.goy
DecuSign Envelope ID: 56C9EB54-D284-4A64-AA21-D9798C215878 |
| MC-350 |
CASE NAME: Callmbang v. Estella Logarta, at al. CASE NUMBER: |
|
1
4. Incident or accident Tha incident or accident occurred as follows: |
a. Date: 02/16/2023 Time: 5:00 p.m. |
b. Place: Mission Street at or around Citrus Avenue, Daly City, CA |
G. Persons involved (names): |
Mikki Catimbang and Estella Logarta bY
[-~] Continued on Attachment 4. | |
5. Nature of incident or accident Hot
The facts, events, and clraumstances of the incident or accident are (describe what happened): .
Mikki Catlmbang waa walking eastoound, crossing Mission Street at Citrus Avenue, in the marked and designated pedestrian i |
crosswalk, Estella Logarta was driving westbound from Mission Plaza and was turing left onto southbound Mission Street, While |
making the left turn, Ms. Logarta collided with Mikki Gatimbang while she was in the marked and designated crosswalk. Mikki was i
Upanded and thrown over the hocd of Ms. Logarta's Prius with her legs going over her head. ;
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[__] Continued on Attachment 5. . bo |
- |
6. Injuries |
The follewing injurias were sustained by the claimant as a result of the Incident or accident (describe): ;
Mikki Catimbang sustalned injury to her Jaw, left log, abrasions on both knees and elbows, brulses on her check, chin arid left hip. po,
She had difficulty opening her jaw. In addition to the physical pain, Mikkl Catimbang has had flashbacks of the incident. DG
| _
[__] Continued on Attachment 6. . |
7. Treatment
The claimant received the following care and treatment for the injuries desorbed In item 6 (describe): :
Mikki Catimbang received several x-rays and a head CT at San Francisco Genaral Hospital, and she was evaluated for head, knee, '
elbow and hip paln. She was told to follow up with her PGP. Mikki followed up with her PGP, Rachel Malina, MD, on 02/21/2023, ° Po
five days after tha incident, Dr. Malina noted abrasions on Mikki's knees and elbows, as well as bruises on her chaak, chin and left ° |
hip. Mikki also had complaints of difficulty opening her jaw. Dr, Malina referred Mikki to physical therapy and Healthy Young Minds |
for therapy.
. |
Continued on Attachment 7,
8. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a dlagnosts of the claimant's Injuries
or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be alfached to this petition as ,
Attachment 8. A new report is not necessary if a previous report accurately describes the claimant's current condition)
a. The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent
injuries. PO
b. [—_] The claimant has not racovered completely from the effects of the injuries described in Item 6, and the following injuries Pp
from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): po
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[__] Continued on Attachment 8b,
c. [__] The claimant has not recovered completely fram the effects of the injuries described In itam 6, and the following Injuries fo
from which the claimant has not recovered are permanent (describe the permanent injuries and’ symptoms):
[__] Continued on Attachment 8c.
i en
MOSDO TRON da taney1 2071
202
PETITION FOR APPROVAL OF COMPROMISE OF CLAIM “age zona |
OR ACTION OR DISPOSITION OF PROGEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ‘
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Docusign Envelope ID: 56C9EB54-D28A-4A64-AA21-D9798C2
15678 ,
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. MC-350
CASE NAME: Gatimbang v. Estella Logarta, ot al, we ; |
9, [3¢] Petitloner has made a careful and diligent inquiry and investigation Into the facts and circumstances of the incident
or accident In which the clalmant was Injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the clalmant's injuries, Petitioner understands that if the compromise proposed in this petition is
fo
approved by the court and consummated, the claimant will nevar be able to recover any more compensation from the
PO
settling defendants named below even if the claimant's Injuries turn out to be more serlous than they now appear. st
16. Amount and terms of settlement
To settle the clalm in 3a or 3b, the defendants named below have offered to pay the following amounts fo the claimant:
a. The total amount offered by all defendants named below Is (specify): $ 58,689.48
b. The defandants and amounte offered by each ars as follows (specify): - 5
Defendants (names) Amounts |
Estella Logarta $ 58,689.48 mi
$ mo
$ |
|} Defendants and amounts offered continued on Attachment 10b.
$ |
a
¢, The terms of settlement ara as follows. (if the settement Is to be paid in instalments, both the fotal amount and the present |
value of the settlement must be Included.) i
fo
[~~] Continued on Attachment 10c, |
!
11. Settlement payments to others :
a. [x] No defendant named in item 10b has offered to pay money to any person or persons other than the clalmant to settle sO
clalms arlsirig out of the same incident or accident that resulted In the claimant's Injury. Do
b. [—_] To settle clams 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 4 person or persons other than claimant. ot
(1) The total amount offered by all defendants to others is (specify): $
(2) Petitioner [“] doesnothave [7] has a claim against the recovery of the claimant (other than for
* reimbursement of fees or expenses paid by petitioner and listed under Item 44). ig
(if you answered ‘has, “explain in Attachment 11b(2) the circumstances and the effect your clam has on the proposed f |
compromise of the claim described in this petition.) |
(3) Petitioner [7] isnot [Jig aptaintiffin the same action with the claimant, | |
(if you answered ‘is," oxplain 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 thls petition) |
(4) [__] Petitioner would receive money under the proposed settlement. :
(5) The settlement payments ara to be apportioned and distributed as follaws: :
Other plaintiffs or claimants (names) Amounts
& |
$ |
$ 1
[_] Additional plaintiffs or claimants and amounts are listed on Attachment 1ib(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 41 4b(4).
er ee
Messe et L ana 1, 2024 4 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM ™
Page 3 of 19
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
,
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}
i
DocuSign Envelope ID: 56C9EB54-D28A-4A64-AA2 1-D9798C215678 !
NC-350
P NAME; Calimbang v. Estella Logarta, et al. er .
12, The claimant's madical expenses—including medical expensas pald by petitioner, Medicare, Med!-Gal, and private :
insurers—to be paid or reimbursed from proceeds of settlement or judgment | |
a, Totals | |
(1) Total medical expenses before any reductions; $ 42,211.62 |
(2) Total medical expenses paid (include payments by private Insurance, Medi-Cal, or Medicare): ($ 17,970.85} |
{3) Total of negotiated, contractual, or statutory reductions, if any: ($ 30,484.44) |
{4) Total medical expenses to be paid or reimbursed from the proceada: $ 11,727.18 :
(5) Total amount of statutory or contractual liens, if any: f 17,970.85 | |
b. Medical expenses were paid and are to be reimbursed from the proceeds as follows: i
(1) [7] Pald by petitioner in the amount of: $ a
{2) [5] Patd by private health insurance or a self-funded plan under; :
{a} [__] An Employee Retirement Income Security Act (ERISA) insured plan. :
{b} [_] An ERISA self-funded plan. Po
{c) [3] A Non-ERISA insured plan. So
{dq} [__] ANon-ERISA self-funded plan. fo
{e} Amount paid by plan: $ 17,689.05
{f) Amount of reimbursement to the plan frorn the proceeds of the settlement or judgment: j
() [["] No reimbursementIs requested by the plan,
(i) [_-] Reimbursement |s to ba made to the plan, and:
(A) [_] There is a contractual reductlon of: ($ bh
(8) [] There Is a negotlated reduction of ($ 6,149.95),
(C) [__] No reduction has been agreed to,
for a total reimbursement to the plan, In full satisfaction of its len rights, inthe amount of: = $ 11,638.70 |
(3) [__] Paid by Medicare in the amount of: ar: po
less the statutory reduction in the amount of: (f ) |
for a total reimbursement to Medicare in the amount of: $ | :
(Attach a copy of the final Medicare demand lettar or letter agreement as Attachment 12b(3),) ‘
(4) [__] Paid by Medi-Cal in the amount of: $ |
(2) [_] Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, Hj
§ 1412473.) A copy of the notice and proof of delivery:
[] is attached = [[_] was filed in this case on (date): .
(>) [_] Notice of this claim or action has not been given to the Diractor of Health Care Services, (Explain why notice has Py
not been given in Attachment 12b(4)(b).) ‘
tc) [__] In full satisfaction of its lien fights, Med|-Cal has agreed to accept retmbursement in the amount of: i
$ po
(Attach a copy of the final Medi-Cal demand fetter or letter agreement as Attachment 12b{4){c),) i
{d) [__] Petitioner Is entitled to a reduction of the Medi-Cal lien under Welfare and Institutlons Gode section 144124.76 and |
{eieck one): |
(i) [J Is filing a motion seaking a reduction of the Hen concurrently with this petition. . ot
(ii) [""] Requests that the court reserva jurisdiction over this lssua. Pt
The amount of the lien in dispute is: $ |
(5) fa) @ There are no statutory or contractual liens for payment of claimant's medical expenses, |
{ij [¢_] There are one or more statutory or contractual liens of medical service providers for payment of claimant's
medical expanses. The total amount claimed under thase liens is: $281.20
In full satisfaction of thelr flen claims, tha lienholders have agreed to accept the sum of $ 187.48
(Provide requested information for each fienholder and other spacified medical service providers on next page.) |
WG-50 [Rev Jewry 1.202
Mean TRen sama 20e PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Pageed densea
OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
DocuSign Envelope IID: 56C9EB54-D28A-4A64-AA21-D9798C
215678 . |
MIC-360
CASE NAME: Gatimbang v, Estella Logarta, et al.
12, Claimant's medical expenses (continued) ,
|to |
b. (8) (b) The name of sach medical service provider that furnished care and treatment to clalmant 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 ralmbursement, 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): Palo Alto Medical Foundation :
(B} Address: P.O, Box 21687 |
Eagan, MN 65124 | |
(C) Amount charged:
| !
$ 3,963.00 |
{D) Amount pald (whether or nat by Insurance); i$ 1,244.38) |
{E) Negotiated reduction, If any: ($ 03.72) |
{F) Amount to be paid from proceeds of settlement or judgment: $ 187.48
(il) (A) Provider (namay:
(B) Address: !
(C) Amount charged: , $ |
(D) Amount paid (whether or not by insurance): ($ ) |
{E) Negotiated reduction, If any: ($ }
{F) Amount to be pald from proceeds of settlament or judgment: $ |
(iil) (A) Provider fname): |
(B) Address: . | !
(CG) Amount charged: $ ,
(0) Armount paid (whether or not by insurance): (6 ) 7
(E} Negotlated reduction, if any: ($ ) mo
(F) Amount to be paid from proceeds of settlement or judgment: $ :
; ["~] 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 7 2b{1), above. |
You may use form MC-380(A-12b(5) for this purpose.) |
13, Clatmant's attorney's fees and all other exporses {except for medical expenses), including expenses advanced by
claimant's attorney or pald or incurred by potitioner, to be relmbursed from proceeds of settlement or judgment |
a. Total amount of attorney's fees for which court approval ia requested: $ 14,672.37 i |
(iF feas are requested, attach as Atiachment 13a a declaration from tho atforney explaining the basis for the request, Including @ { |
discussion of applicable factors listed in rule 7.955(b) of the Cal, Rules of Court. Respond to item 17a(2) on page 7 and aitach a / |
copy of any written attorney fee agreement as Aflachment 17a.) |
b. The following additional items of expense (other than medical expenses) have been incurred or paid, are Teasonable, resulted
from the Incident or accident, and should be pald out of claimant's share of the proceeds of the sattlament or judgment: oo:
Items Payees (names) Amounts
Records Retriaval Fees Penney & Associates $ 95,35 |
G.A.L. & Minor's Gomp Filing Faes Penney & Associates § 496,20 bog
Acknowledgment of Recelpt Fillng Fees Penney & Associates $ 13.92 |
Request for Diemissal Filing Fees Penney & Associates $ 13.92 i
Soft Costs, Postage and Copy Fees Penney & Associates
|
$ 75.00 j
$ |
[__] Gontinued on Attachment 13b. Total: $
$
693.39
1
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Mee ey 8 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page Sorte —
ae
OR ACTION OR DISPOSITION OF PROCEEDS OF i
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
DocuSign Envelope ID: 56C9EB54-D28A-4464-AA21-D9798C215678
| NIG-850 |
CASE NAME: Callmbang v. Eatella Logarta, et al, :
14. Relmbursement of fees and expenses paid by petitionor
a, [3] Petitioner has paid none of the fees or expenses listed In items 12 and 43 for which relmbursement is requested. |
b, [_] Petitioner has paid (or become obligated to pay) the follewing total amounts of the claimant's fees and expenses for which :
ralmbursement Is requested, |
(1) [-_] Medica
Preview
DocuSign Envelope ID: 58C9EB64-D28A-4A64-AA21-D9788C215678 | MG-350 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: 397.347 FOR COURT USE ONLY NAVE: Garratt M. Penney | FIRM NAME: PENNEY & ASSOCIATES STREET ADDRESS; {490 Stone Point Drive, Suite 150 Do cit: Roseville STATE: CA AIP CODE: 956861 | TELEPHONE NO. 948-786-7662 FAXNO.: 916-786-0144 | EMAIL ADDRESS: gnenney@penneylawyer.com ATTORNEY FOR (Went: Mikki Gatimbang ; SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO | STREET ADDRESS: 40Q County Center, 1st Floor, Room A | MAILING ADDRESS: ; | CITY AND ZIP GODE: Redwood City, CA 84063 p | BRANCH NAME: Southern Branch: Hail of Justice and Records | | CASE NAME: CASE NUMBER | Catimbang v. Estella Logarta, at al. HEARING DATE: PETITION FOR APPROVAL OF COMPROMISE OF CLAIM fee OR ACTION OR DISPOSITION OF PROCEEDS OF TE: | JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY prem | NOTICE TO PETITIONER bo 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 @ minor or a person with 4 disability (including a | conservates) Is a party, or (3) the disposition of the proceeds of a judgment awarded to a minor or a person with a disability. (See | Gade Giv. 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 PO 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 proceads of certaln judgments. To determing whether your clalm, action, or Judgment qualifies, see Cal. Rules too: of Court, rule 7,950.5, {f you want to request expedited considaration, you must use form MC-350EX, 1. Petitioner (name or pseudonym*): Miguel Catimbang ‘ is the (check al boxes that apply): = (4¢] Parent (3€] Guardian ad litem* [77] Guardian [7] Conservator [__] Other (specify relaifonship): : of the claimant Identified in Item 2. (*Petitfoner may appear undera pseudonym only if appointed as guardian ad litem under that : pseudonym. (See Code Gly. Proo., § 372.5) Po 2. Claimant (name): Mikkl Catimbang po a. Addreas: 550 Clark Avenue, Colma, CA 94014 b. Date of birth: 07/27/2008 ’ 9. Age: 15 d. (3¢] Minor or [__] Person with a dlsability | (if ihe claimant is an adult with a disability who (1) has capacity ta consent to the ordor requested and (2) does not have a : - conservator of the estate, check a. and f. and ensure that the claimant personally reads and signs lem 21. (Prob. Code, § 3613.) | e. [|__| Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order or Judgment. fo f, ["] Boes not have a conservator of the estate. — 3, Claim The claim of the minor or adult person with 4 disability (check one): a. [2] Is not the subject of a pending action or proceeding. (Complete items 4-23.) , b, [__] Is the subject of a pending action or proceeding that will ba compromised or settled without a trial. {(Gomplete items 4-23.) Name of court: i Case na: Trial date: i, c. [__] Is the subject of an action or proceeding in which a judgment hag been or will be entered for the claimant against the | ‘ defendants named below In the amount (excluding interest and sosts) of (specify total): $ : an Defendants {names: o [_] Additional defendants listed on Attachment 3. | [___] The judgment was filed on (date): (Atfach a capy of the (proposed) judgment as Aifachmont 3c and complete items 12-23.) Pago of 40 ARE 1A A rome Maney Use Judlefal Counell of Callfomia PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Pacate eo, 43800, 000-0 ! OR ACTION OR DISPOSITION OF PROCEEDS OF Gal. Rules of Cou, rutes 3,1384, . MC-380 [Rov, J mane 1, 2024] JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 7.10, 7,050-7,882 win cours.ca.goy DecuSign Envelope ID: 56C9EB54-D284-4A64-AA21-D9798C215878 | | MC-350 | CASE NAME: Callmbang v. Estella Logarta, at al. CASE NUMBER: | | 1 4. Incident or accident Tha incident or accident occurred as follows: | a. Date: 02/16/2023 Time: 5:00 p.m. | b. Place: Mission Street at or around Citrus Avenue, Daly City, CA | G. Persons involved (names): | Mikki Catimbang and Estella Logarta bY [-~] Continued on Attachment 4. | | 5. Nature of incident or accident Hot The facts, events, and clraumstances of the incident or accident are (describe what happened): . Mikki Catlmbang waa walking eastoound, crossing Mission Street at Citrus Avenue, in the marked and designated pedestrian i | crosswalk, Estella Logarta was driving westbound from Mission Plaza and was turing left onto southbound Mission Street, While | making the left turn, Ms. Logarta collided with Mikki Gatimbang while she was in the marked and designated crosswalk. Mikki was i Upanded and thrown over the hocd of Ms. Logarta's Prius with her legs going over her head. ; | [__] Continued on Attachment 5. . bo | - | 6. Injuries | The follewing injurias were sustained by the claimant as a result of the Incident or accident (describe): ; Mikki Catimbang sustalned injury to her Jaw, left log, abrasions on both knees and elbows, brulses on her check, chin arid left hip. po, She had difficulty opening her jaw. In addition to the physical pain, Mikkl Catimbang has had flashbacks of the incident. DG | _ [__] Continued on Attachment 6. . | 7. Treatment The claimant received the following care and treatment for the injuries desorbed In item 6 (describe): : Mikki Catimbang received several x-rays and a head CT at San Francisco Genaral Hospital, and she was evaluated for head, knee, ' elbow and hip paln. She was told to follow up with her PGP. Mikki followed up with her PGP, Rachel Malina, MD, on 02/21/2023, ° Po five days after tha incident, Dr. Malina noted abrasions on Mikki's knees and elbows, as well as bruises on her chaak, chin and left ° | hip. Mikki also had complaints of difficulty opening her jaw. Dr, Malina referred Mikki to physical therapy and Healthy Young Minds | for therapy. . | Continued on Attachment 7, 8. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a dlagnosts of the claimant's Injuries or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be alfached to this petition as , Attachment 8. A new report is not necessary if a previous report accurately describes the claimant's current condition) a. The claimant has recovered completely from the effects of the injuries described in item 6, and there are no permanent injuries. PO b. [—_] The claimant has not racovered completely from the effects of the injuries described in Item 6, and the following injuries Pp from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): po | [__] Continued on Attachment 8b, c. [__] The claimant has not recovered completely fram the effects of the injuries described In itam 6, and the following Injuries fo from which the claimant has not recovered are permanent (describe the permanent injuries and’ symptoms): [__] Continued on Attachment 8c. i en MOSDO TRON da taney1 2071 202 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM “age zona | OR ACTION OR DISPOSITION OF PROGEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ‘ | Docusign Envelope ID: 56C9EB54-D28A-4A64-AA21-D9798C2 15678 , | . MC-350 CASE NAME: Gatimbang v. Estella Logarta, ot al, we ; | 9, [3¢] Petitloner has made a careful and diligent inquiry and investigation Into the facts and circumstances of the incident or accident In which the clalmant was Injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the clalmant's injuries, Petitioner understands that if the compromise proposed in this petition is fo approved by the court and consummated, the claimant will nevar be able to recover any more compensation from the PO settling defendants named below even if the claimant's Injuries turn out to be more serlous than they now appear. st 16. Amount and terms of settlement To settle the clalm in 3a or 3b, the defendants named below have offered to pay the following amounts fo the claimant: a. The total amount offered by all defendants named below Is (specify): $ 58,689.48 b. The defandants and amounte offered by each ars as follows (specify): - 5 Defendants (names) Amounts | Estella Logarta $ 58,689.48 mi $ mo $ | |} Defendants and amounts offered continued on Attachment 10b. $ | a ¢, The terms of settlement ara as follows. (if the settement Is to be paid in instalments, both the fotal amount and the present | value of the settlement must be Included.) i fo [~~] Continued on Attachment 10c, | ! 11. Settlement payments to others : a. [x] No defendant named in item 10b has offered to pay money to any person or persons other than the clalmant to settle sO clalms arlsirig out of the same incident or accident that resulted In the claimant's Injury. Do b. [—_] To settle clams 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 4 person or persons other than claimant. ot (1) The total amount offered by all defendants to others is (specify): $ (2) Petitioner [“] doesnothave [7] has a claim against the recovery of the claimant (other than for * reimbursement of fees or expenses paid by petitioner and listed under Item 44). ig (if you answered ‘has, “explain in Attachment 11b(2) the circumstances and the effect your clam has on the proposed f | compromise of the claim described in this petition.) | (3) Petitioner [7] isnot [Jig aptaintiffin the same action with the claimant, | | (if you answered ‘is," oxplain 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 thls petition) | (4) [__] Petitioner would receive money under the proposed settlement. : (5) The settlement payments ara to be apportioned and distributed as follaws: : Other plaintiffs or claimants (names) Amounts & | $ | $ 1 [_] Additional plaintiffs or claimants and amounts are listed on Attachment 1ib(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 41 4b(4). er ee Messe et L ana 1, 2024 4 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM ™ Page 3 of 19 OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY , | | } i DocuSign Envelope ID: 56C9EB54-D28A-4A64-AA2 1-D9798C215678 ! NC-350 P NAME; Calimbang v. Estella Logarta, et al. er . 12, The claimant's madical expenses—including medical expensas pald by petitioner, Medicare, Med!-Gal, and private : insurers—to be paid or reimbursed from proceeds of settlement or judgment | | a, Totals | | (1) Total medical expenses before any reductions; $ 42,211.62 | (2) Total medical expenses paid (include payments by private Insurance, Medi-Cal, or Medicare): ($ 17,970.85} | {3) Total of negotiated, contractual, or statutory reductions, if any: ($ 30,484.44) | {4) Total medical expenses to be paid or reimbursed from the proceada: $ 11,727.18 : (5) Total amount of statutory or contractual liens, if any: f 17,970.85 | | b. Medical expenses were paid and are to be reimbursed from the proceeds as follows: i (1) [7] Pald by petitioner in the amount of: $ a {2) [5] Patd by private health insurance or a self-funded plan under; : {a} [__] An Employee Retirement Income Security Act (ERISA) insured plan. : {b} [_] An ERISA self-funded plan. Po {c) [3] A Non-ERISA insured plan. So {dq} [__] ANon-ERISA self-funded plan. fo {e} Amount paid by plan: $ 17,689.05 {f) Amount of reimbursement to the plan frorn the proceeds of the settlement or judgment: j () [["] No reimbursementIs requested by the plan, (i) [_-] Reimbursement |s to ba made to the plan, and: (A) [_] There is a contractual reductlon of: ($ bh (8) [] There Is a negotlated reduction of ($ 6,149.95), (C) [__] No reduction has been agreed to, for a total reimbursement to the plan, In full satisfaction of its len rights, inthe amount of: = $ 11,638.70 | (3) [__] Paid by Medicare in the amount of: ar: po less the statutory reduction in the amount of: (f ) | for a total reimbursement to Medicare in the amount of: $ | : (Attach a copy of the final Medicare demand lettar or letter agreement as Attachment 12b(3),) ‘ (4) [__] Paid by Medi-Cal in the amount of: $ | (2) [_] Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, Hj § 1412473.) A copy of the notice and proof of delivery: [] is attached = [[_] was filed in this case on (date): . (>) [_] Notice of this claim or action has not been given to the Diractor of Health Care Services, (Explain why notice has Py not been given in Attachment 12b(4)(b).) ‘ tc) [__] In full satisfaction of its lien fights, Med|-Cal has agreed to accept retmbursement in the amount of: i $ po (Attach a copy of the final Medi-Cal demand fetter or letter agreement as Attachment 12b{4){c),) i {d) [__] Petitioner Is entitled to a reduction of the Medi-Cal lien under Welfare and Institutlons Gode section 144124.76 and | {eieck one): | (i) [J Is filing a motion seaking a reduction of the Hen concurrently with this petition. . ot (ii) [""] Requests that the court reserva jurisdiction over this lssua. Pt The amount of the lien in dispute is: $ | (5) fa) @ There are no statutory or contractual liens for payment of claimant's medical expenses, | {ij [¢_] There are one or more statutory or contractual liens of medical service providers for payment of claimant's medical expanses. The total amount claimed under thase liens is: $281.20 In full satisfaction of thelr flen claims, tha lienholders have agreed to accept the sum of $ 187.48 (Provide requested information for each fienholder and other spacified medical service providers on next page.) | WG-50 [Rev Jewry 1.202 Mean TRen sama 20e PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Pageed densea OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY DocuSign Envelope IID: 56C9EB54-D28A-4A64-AA21-D9798C 215678 . | MIC-360 CASE NAME: Gatimbang v, Estella Logarta, et al. 12, Claimant's medical expenses (continued) , |to | b. (8) (b) The name of sach medical service provider that furnished care and treatment to clalmant 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 ralmbursement, 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): Palo Alto Medical Foundation : (B} Address: P.O, Box 21687 | Eagan, MN 65124 | | (C) Amount charged: | ! $ 3,963.00 | {D) Amount pald (whether or nat by Insurance); i$ 1,244.38) | {E) Negotiated reduction, If any: ($ 03.72) | {F) Amount to be paid from proceeds of settlement or judgment: $ 187.48 (il) (A) Provider (namay: (B) Address: ! (C) Amount charged: , $ | (D) Amount paid (whether or not by insurance): ($ ) | {E) Negotiated reduction, If any: ($ } {F) Amount to be pald from proceeds of settlament or judgment: $ | (iil) (A) Provider fname): | (B) Address: . | ! (CG) Amount charged: $ , (0) Armount paid (whether or not by insurance): (6 ) 7 (E} Negotlated reduction, if any: ($ ) mo (F) Amount to be paid from proceeds of settlement or judgment: $ : ; ["~] 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 7 2b{1), above. | You may use form MC-380(A-12b(5) for this purpose.) | 13, Clatmant's attorney's fees and all other exporses {except for medical expenses), including expenses advanced by claimant's attorney or pald or incurred by potitioner, to be relmbursed from proceeds of settlement or judgment | a. Total amount of attorney's fees for which court approval ia requested: $ 14,672.37 i | (iF feas are requested, attach as Atiachment 13a a declaration from tho atforney explaining the basis for the request, Including @ { | discussion of applicable factors listed in rule 7.955(b) of the Cal, Rules of Court. Respond to item 17a(2) on page 7 and aitach a / | copy of any written attorney fee agreement as Aflachment 17a.) | b. The following additional items of expense (other than medical expenses) have been incurred or paid, are Teasonable, resulted from the Incident or accident, and should be pald out of claimant's share of the proceeds of the sattlament or judgment: oo: Items Payees (names) Amounts Records Retriaval Fees Penney & Associates $ 95,35 | G.A.L. & Minor's Gomp Filing Faes Penney & Associates § 496,20 bog Acknowledgment of Recelpt Fillng Fees Penney & Associates $ 13.92 | Request for Diemissal Filing Fees Penney & Associates $ 13.92 i Soft Costs, Postage and Copy Fees Penney & Associates | $ 75.00 j $ | [__] Gontinued on Attachment 13b. Total: $ $ 693.39 1 | Mee ey 8 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM Page Sorte — ae OR ACTION OR DISPOSITION OF PROCEEDS OF i JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY DocuSign Envelope ID: 56C9EB54-D28A-4464-AA21-D9798C215678 | NIG-850 | CASE NAME: Callmbang v. Eatella Logarta, et al, : 14. Relmbursement of fees and expenses paid by petitionor a, [3] Petitioner has paid none of the fees or expenses listed In items 12 and 43 for which relmbursement is requested. | b, [_] Petitioner has paid (or become obligated to pay) the follewing total amounts of the claimant's fees and expenses for which : ralmbursement Is requested, | (1) [-_] Medica