Preview
FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020
STATE OF NEW YORK
SUPREME COURT : COUNTY OF CHAUTAUQUA
In the Matter of the Application of
KAREN SMITH, Individually and as Parent and Natural
Guardian of B.S., an Infant
PETITION TO
SETTLE CLAIM
Petitioner Index No.
Petitioner KAREN SMITH, individually and as parent and natural guardian of B.S., an
Infant, being duly sworn, states as follows:
1. Your Petitioner is the parent and natural guardian of B.S., who is an Infant having
been born on XXXXXXX, 2005, presently fourteen years of age, and that your Petitioner and her
son reside at 10522 Creek Road, Forestville, New York.
2. I make this Petition in support of an application to settle an action on behalf of my
son, B.S., as against myself.
3. On November 28, 2017, my son, B.S., was a passenger in my motor vehicle
operated by me which was involved in a two car motor vehicle accident injuring my son, B.S.
Attached to my Petition is a copy of the Police Accident Report (Exhibit 1).
4. Following said accident, B.S., was transported to Brooks Memorial Hospital
where he was examined and treated for a fracture of his right elbow described as an avulsion
fracture. Please refer to Exhibit 2. He was placed in a sling and referred to Lakeshore
Orthopedic Group.
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FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020
5. Attached as Exhibit 3 are medical records from Lakeshore Orthopedic Group
dated November 30, 2017 and January 3, 2018. As of January 3, 2018, the physician returned
my son to gym and sports without limitation. He has not been seen by this group since.
6. As of the date of this Petition, all medical and related expenses of the Infant, B.S.,
arising out of the accident of November 28, 2017 have been paid.
7. I have not retained an attorney in connection with my son's personal injury claim
and am fully aware that the law firm of BURGIO, CURVIN & BANKER, has been retained by
Garrison Property & Casualty Insurance Company to prepare this Petition and Order. In the
event that this Petition is approved by the presiding Judge, I understand that the attorney's fees
for these services will be paid by Garrison Property & Casualty Insurance.
8. I have discussed my son's case with representatives of Garrison Property &
Casualty Insurance and have agreed to accept the settlement of all causes of action arising out of
his personal injuries in a structured settlement to be provided by Pacific Life & Annuity
Company. The sum of $22,500.00 will be utilized to fund the structured settlement annuity
underwritten by Pacific Life & Annuity Company (rated A+ superior by A.M. Best Company)
for the benefit of B.S., a minor. Said annuity will provide the following periodic payments:
• $5,000.00 sum, guaranteed, paid on 12, 2023;
lump July
• $7,500.00 lump sum, guaranteed, paid on July 12, 2027;
• $13,288.00 sum, guaranteed, paid on 12, 2030.
lump July
9. Garrison Property & Casualty Insurance Company shall issue
payment in the amount of $22,500.00 made payable to Pacific Life & Annuity
payments"
Services, Inc. which shall in turn fund the "periodic by purchasing a
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FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020
qualified funding asset within the meaning of §l30(d) of the Internal Revenue
Code of 1986 in the form of an annuity contract issued by Pacific Life & Annuity
Company. The parties to this settlement shall cooperate fully and execute any and
all supplementary documents, including the qualified assignment document, and
to take all additional actions which may be necessary or appropriate to give full
force and effect to the basic terms and intent of this settlement (Please refer to
Exhibit 4).
"8"
10. I believe that the proposed settlement as set forth in paragraph
is fairand equitable and should be accepted in the best interest of said Infant.
11. Since there are no attorney's fees to be paid by myself, the net
recovery for the Infant, B.S., will be $25,788.00 as set forth in Exhibit 4.
12. No previous application for the relief herein requested for has been made.
WHEREFORE, your Petitioner, KAREN SMITH, requests an Order be entered
approving the proposed settlement of the claim of this Infant, B.S., together with all derivative
causes of action, for the sum set out in the proposed structured settlement attached as Exhibit 4,
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FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020
as more fully stated in this Petition.
DATED: 5 , 2020
Forestville, New York
REN S IITH, Ind. and as Parent
and Natural Guardian of
B.S., an Infant
Sworn to before me this
__.5__ day of January, 2020.
Notary Pu lic
CARLYN J SZAROWICZ
NOTARY PUBLIC STATE OF NEW YORK
ERIE
LIC.#01SZ6320817
COMM. EXP. 03/09/2023
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NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020
VERIFICATION
STATE OF NEW YORK )
) ss.
COUNTY OF CHAUTAUQUA)
KAREN SMITH, being duly sworn, deposes and says that she is the Petitioner in this
action; that she read the foregoing Petition to Settle Claim and knows the contents thereof; that
the same is true to the knowledge of deponent, except as to the matters therein stated to be
alleged on information and belief, and that as to those matters she believes itto be true.
KA EN SM , as Parent and Natural
Guardian of B.S., an Infant
Sworn to before me this
day ofFe , 2020
Notary Public
AMBER A WlKTOROWSKI
NOTARY PUBLIC STATE OF NEW YORK
ERIE
LIC.#01Wl6377459
COMM. EXP. 07/02/2022
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Preview
FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020 STATE OF NEW YORK SUPREME COURT : COUNTY OF CHAUTAUQUA In the Matter of the Application of KAREN SMITH, Individually and as Parent and Natural Guardian of B.S., an Infant PETITION TO SETTLE CLAIM Petitioner Index No. Petitioner KAREN SMITH, individually and as parent and natural guardian of B.S., an Infant, being duly sworn, states as follows: 1. Your Petitioner is the parent and natural guardian of B.S., who is an Infant having been born on XXXXXXX, 2005, presently fourteen years of age, and that your Petitioner and her son reside at 10522 Creek Road, Forestville, New York. 2. I make this Petition in support of an application to settle an action on behalf of my son, B.S., as against myself. 3. On November 28, 2017, my son, B.S., was a passenger in my motor vehicle operated by me which was involved in a two car motor vehicle accident injuring my son, B.S. Attached to my Petition is a copy of the Police Accident Report (Exhibit 1). 4. Following said accident, B.S., was transported to Brooks Memorial Hospital where he was examined and treated for a fracture of his right elbow described as an avulsion fracture. Please refer to Exhibit 2. He was placed in a sling and referred to Lakeshore Orthopedic Group. 1 of 5 FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020 5. Attached as Exhibit 3 are medical records from Lakeshore Orthopedic Group dated November 30, 2017 and January 3, 2018. As of January 3, 2018, the physician returned my son to gym and sports without limitation. He has not been seen by this group since. 6. As of the date of this Petition, all medical and related expenses of the Infant, B.S., arising out of the accident of November 28, 2017 have been paid. 7. I have not retained an attorney in connection with my son's personal injury claim and am fully aware that the law firm of BURGIO, CURVIN & BANKER, has been retained by Garrison Property & Casualty Insurance Company to prepare this Petition and Order. In the event that this Petition is approved by the presiding Judge, I understand that the attorney's fees for these services will be paid by Garrison Property & Casualty Insurance. 8. I have discussed my son's case with representatives of Garrison Property & Casualty Insurance and have agreed to accept the settlement of all causes of action arising out of his personal injuries in a structured settlement to be provided by Pacific Life & Annuity Company. The sum of $22,500.00 will be utilized to fund the structured settlement annuity underwritten by Pacific Life & Annuity Company (rated A+ superior by A.M. Best Company) for the benefit of B.S., a minor. Said annuity will provide the following periodic payments: • $5,000.00 sum, guaranteed, paid on 12, 2023; lump July • $7,500.00 lump sum, guaranteed, paid on July 12, 2027; • $13,288.00 sum, guaranteed, paid on 12, 2030. lump July 9. Garrison Property & Casualty Insurance Company shall issue payment in the amount of $22,500.00 made payable to Pacific Life & Annuity payments" Services, Inc. which shall in turn fund the "periodic by purchasing a 2 of 5 FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020 qualified funding asset within the meaning of §l30(d) of the Internal Revenue Code of 1986 in the form of an annuity contract issued by Pacific Life & Annuity Company. The parties to this settlement shall cooperate fully and execute any and all supplementary documents, including the qualified assignment document, and to take all additional actions which may be necessary or appropriate to give full force and effect to the basic terms and intent of this settlement (Please refer to Exhibit 4). "8" 10. I believe that the proposed settlement as set forth in paragraph is fairand equitable and should be accepted in the best interest of said Infant. 11. Since there are no attorney's fees to be paid by myself, the net recovery for the Infant, B.S., will be $25,788.00 as set forth in Exhibit 4. 12. No previous application for the relief herein requested for has been made. WHEREFORE, your Petitioner, KAREN SMITH, requests an Order be entered approving the proposed settlement of the claim of this Infant, B.S., together with all derivative causes of action, for the sum set out in the proposed structured settlement attached as Exhibit 4, 3 of 5 FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020 as more fully stated in this Petition. DATED: 5 , 2020 Forestville, New York REN S IITH, Ind. and as Parent and Natural Guardian of B.S., an Infant Sworn to before me this __.5__ day of January, 2020. Notary Pu lic CARLYN J SZAROWICZ NOTARY PUBLIC STATE OF NEW YORK ERIE LIC.#01SZ6320817 COMM. EXP. 03/09/2023 4 of 5 FILED: CHAUTAUQUA COUNTY CLERK 03/04/2020 02:34 PM INDEX NO. EK12020000388 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/04/2020 VERIFICATION STATE OF NEW YORK ) ) ss. COUNTY OF CHAUTAUQUA) KAREN SMITH, being duly sworn, deposes and says that she is the Petitioner in this action; that she read the foregoing Petition to Settle Claim and knows the contents thereof; that the same is true to the knowledge of deponent, except as to the matters therein stated to be alleged on information and belief, and that as to those matters she believes itto be true. KA EN SM , as Parent and Natural Guardian of B.S., an Infant Sworn to before me this day ofFe , 2020 Notary Public AMBER A WlKTOROWSKI NOTARY PUBLIC STATE OF NEW YORK ERIE LIC.#01Wl6377459 COMM. EXP. 07/02/2022 5 of 5