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OB..GINAL MC-350
ATTORNEY 0R PARTY WITHOUT ATTORNEY State Barnumber. and address): FOR COURT USE ONLY
bNZnée.
Paul E. Lee (Bar # 172
—~ AA-Accident Attorne
s, PL
4700 Teller Ave, 2n Floor
Newport Beach, CA 92660
TEEPHONE N0.: (949) 660-8753 FAX No. (Optlonal): (949) 660.8720
FEEED
E-MAIL ADDRESS (Optional)!
SAN MATEO COUNTY
RENEE CRONIN, Petitioner
ATTORNEY FOR (Name):
SEP 1 0 2016
SUPERIOR coum OF CALIFORNIA, COUNTY OF SAN MATEO
STREETADDRESS: 400 County Center Clarke e eriorCoun
MAILING ADDRESS: 400 County Center
5y
CITYANDZIP CODE: Redwood 94063 DEPI] INKEHK
amen NAMEI Superior Court
FAX
CASE NAME;
IN THE MATTER OF ANAYA ALISA PRIMES 1t c Iii t it e it
PETITION TO APPROVE: l1]
COMPROMISE OF DISPUTED CLAIM
HEARING DATE:
BY
lII COMPROMISE 0F PENDING ACTION i OIQQA l $0
1:1 DISPOSITION 0F PROCEEDS OF JUDGMENT
Minor III
Person With a Disability
NOTICE TO PETITIONERS:
DEPT:
PI TIME:
0110060,] l
Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor, lOlQ?
(2) the compromise of a pending action or proceedlng in which a minor or a person with a disability (including a ocnservatee) is a
party, or (3) the disposition of the proceeds of a judgment for a minor er person with a disability. (See Code Civ. Proc., § 372; Prob.
Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or
t3
examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment,
and hospitalization. The court may consider on an expedited basis without a hearing requests for approval of the compromises of
certain claims and actions or the disposition of the proceeds of certain judgments. lf your claim, action, orjudgment qualifies for
expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule
7.9505.
1, Petitioner (name): RENBE'CRONTN
'2. Claimant (name): Anaya Alisa Primes
a. Address: 1854 W. Bayshore Rd. #11, East Palo Alto, CA 94303
b. Date of birth: 7/21/2015 c.
.
Age: l d. Sex: Female e. Minor l__—_l Person withadisability
3. Relationship Petitioner's relationship to the claimant (check all applicable boxes):
a.
b.
Parent
III
Guardian ad litem
g. l:l
Other relationship (specify:)
c. [:Il
Guardian
d. III
Conservator
e. 1:]
Disabled adult claimant is a petitioner. (See instructions for items 3e and 3f below.)
f, [:1
Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 8t.
'
(if you checked item 3e or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate
Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not
have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.)
4. Nature of claim The claim of the minor or adult person with a disability:
a. Has not been filed in an action or proceeding. (Complete items 5-23.)
b. III is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.
Name of court:
Case no.: Trial date: (Complete items 5-23.)
. Page 1 of 10
Cede ct Civil Procedure, § 372 et seq;
Form Adopted tor PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
Allemallve Mandatory Use _ Probate Coda. § 3500 el seq;
Judicial Council of Caillctnia OR PENDING ACTION OR DISPOSITION OF PROCFF“e C“:- b5 3.1384.
MC-350 lRev. January 1, 2011] 15-0LJ-01432 350. 7.951
JUDGMENT FOR MINOR OR PERSON WITH A DI!’ PET .
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(Miscellaneous) Petition Filed
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4. Nature of claim The claim oi the minor or adult person with a disability:
c. |:l Is the subject'of a pending action or proceeding that has been or will be reduced to a judgment tor the claimant against
the defendants named below in the total amount (exclusive of interest and costs) oi (specify below):
sl T
Defendants memes!
C] Additional defendants listed on Attachment _4. [:1
The Iudgment was tiled on (date):
(Attach a copy of the (proposed) judgment as Attachment 4c end complete items 13-23.)
5. [Z] incident or accident The incident or accident occurred as tollowe:
a. Date and time: July 14, 2015 at 3:40P.M.~
'
\
- b. Place: Burlingame, CA
c. Parsons Involved (names): Renee Cronin (mother) and Fermin Alfredo Angulo
6.‘
[I] Continued on Attachment 5.
Nature of incident or accident
The |tacts events, and circumstances of the incident or accident are (describe): _
Renee Cronin was 7 months pregnant when shc was rcarcnded by the defendant Fermm A. Angulo, the
imtiact caused Renee's vehicle to plunge forward and strike the vehicle in front of her.
i
l
Cl Continued on Attachment 6.
7. I3] injuries
Thel following injuries were sustained by the claimant as a result of the incident or accident (described;
Renee Cromn (mother) was advrsed by paramedics to seek immediate care due to e stage of her
pregnancy-
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i
[I]
i
Continued on Attachment 7.
8. [I] Trehtment
The‘ cl lm rece e the l
llow‘n care nd t ent for sc
.
in u :
Renee mo er was 3cm tlrcR maimmgélfie'ii taken télhs>orlanriiletise1gr$eryfgaigditegs ‘lgllbglthitsifiilg'iiham Kim Thu, MD. who
tiiYsogaz-ged
coniiirmed her baby was alive. She was then held for observation and discharged with instructions to count the babies kicks and rctum if any pain
pers sts.
Ren'ee immediately began experiencing painiirl contractions a tow hours following her observation in the hospital. She was experiencing increasing
and relentless pain due to the stress and force oi‘ impact. Renee suffered for three days following the accident and on July l7ih, 2015, as pain seized to
subside, she returned to the hospital where she was immediately admitted due to preterm premature rupture of the fetal membranes (PPROM), She was
immediately induced into pre-tenn labor. Ultimately she was given an emergency C-Section in cfi'orts to protect Renee and the baby. Her baby was
bom 3 months premature. Anaya Primes was born 3 months premature and is currently under her pediatricians core to record the progress other
gevclopeinglcrathedlatest report demonstrate that she in on course with her developcment compared with other children her ago had she been born on
or sche e ue etc. ‘
E] Continued on Attachment a.
WWW- January HO"! PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM PM“ 1° '
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OR PENDING ACTION OR DISPOSITION 0F PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH ADISABILITY
(Miscellaneous)
LexisNexisiE Automated Cali/brutalJudtclat Council Forms
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CASE NAME: -
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P IN THE MATTER OF ANAYA ALISA PRIMES
9. Extent of injuries and recovery (An original ora photocopy of ell doctors’ reports containing a diagnosis of and prognosis
for the claimant's injuries. and e report oi‘ the claimant's present condition, must be attached to this petition as Attachment 9.
A new report is not necessary so long es a previous report accurately describes the claimant's current condition.)
a. The claimant hes recovered completely from the effects of the injuries described in Item 7. and there are no
permanent inluries.
b. [:3 The claimant has not recovered completely from the effects of the injuries described in Item 7, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries):
I: Continued on Attachment 9b
c. II] The claimant has not recovered completely from the effects of the lniuries described in Item 7, end the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries):
III] Continued on Attachment 90. ,
10. III Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or
accident in which the claimant was Injured; the responsibility for the Incident or accident; and the nature, extent,
and seriousness of the claimants injuries Petitioner fully understands that if the compromise proposed in this
petition is approved by the court and ls consummated, the claimant will be forever barred from seeking any further
recovery of compensation from the settling defendants named below even though the claimant's Injuries may in.
the future appear to be more serious than they are now thought to be
11 . Amount and terms of settlement
By way of settlement. the defendants named below have offered to pay the following sums to the claimant:
a. The total amount offered by ell defendants named below is (specify): $I 15,000,0()I
b. The defendants and amounts offered by each are as follows (specify): '
De names
Fermin A. Angulo (Foremost Ins.)
Am
15,000.00
69€969€9<69
III Defendants and amounts offered continued on Attachment 11.
c. The terms of settlement are es follows (if the settlement ls lo be paid in installments, both the total amount end the
present value of the settlement must be included):
“:1 Continued on Attachment 11
Mc-WIRW-MWY 1-20'11 PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pee-tom
‘
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF ~
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
Lexlcxls® Automated California Judicial Carma-it Forms
CASE NAME: Cson.
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IN THE MATTER OF ANAYA ALISA PRIMES
12. E3 Settlement payments to others ,
a. 1:] No defendant named in item 11b 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. By way of settlement, one or more defendants named In item 11b have also offered to pay money to a person or
persons other than claimant to settle claims arising out of the same incident or accident that resulted in the
claimant's Injury. -
(1) The total amount offered by all defendants to others (specify): $ 15, 000 00
(2) Petitioner —is not [:1
is a claimant against the recovery of the claimant (other than for
reimbursement for expenses paid by petitioner and listed under item 15).
-
(it you answered”is, "explain in Attachment 12 the circumstances and the effect your claim has on the
proposed com immise of the claim described in this petition)
(3) Petitioner is not [:1
is a plaintiff in the same action with the claimant.
(if you answered rs, "explain in Attachment 12 th'e circumstances and the effect your claim and its disposition
has on the proposed compromise of the claim or action described in this petition )
(4) [I] Petitioner would receive money under the proposed settlement
(6) The settlement payments are to be apportioned and distributed as follows:
Oher Ia s r aI n nam s Amougts
Renee Cronin 15,000.00
$698,“
E]Additional plaintiffs or claimants and amounts are listed on Attachment 12.
(6) Reasons for the apportionment of the settlement payments between the claimant and each other
plaintiff or claimant named above are specified on Attachment 12.
13. The claimant's medical expenses, including medical expenses paid by petitioner and Insurers, to be reimbursed from
proceeds of settlement or judgment
a. Totals .
(1) Total medical expenses: s 335271400
[:I:
(2) Total outstanding medical expenses to be paid from the proceeds: $
(3) Total out-of-pocket, co-payments. or deductible payments to be reimbursed from proceeds: $
b. Medical expenses were paid and are to be reimbursed from proceeds as follows:
(1) [:1 Paid by petitioner In the amount of: $
II] Paid by private health insurance or a self-funded plan under.
(2)
(a)
(b)
I:
I: An Employee Retirement Income Security Act (ERISA) Insured plan.
An ERISA self-funded plan.
(c) III
A Non-ERISA insured plan.
(d) III
A Non-ERISA self-funded plan.
-[:l‘No
(e) Amount paid by plan: $ 335,714. 00
(i) Amount of reimbursement to the plan from proceeds of settlement or judgment:
(i) reimbursement is requested by the plan.
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(It)
,
Reimbursement Is to be made to the plan and:
(A)
(B)
(c)
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1::1
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There is a contractual reduction of $(
There is a negotiated rechrctlon of $ (
No reduction has been agreed to,
for a total reimbursement to the plan In the amount of:
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION 0F PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
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CASE NAME: oAse uuuesm
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13. The claimant's medical expenses. Including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
b Medical expenses were paid and are to be reimbursed from proceeds as follows:
(3)
(4)
[I
II]
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Paid by Medicare in the amount of:
lees the statutory reduction In the amount of: $ t
for a total reimbursement to Medicare In the amount of:
$
)
(Attach a copy ofthe iinai Medicare demand letter or ietter agreement as Attachment i3b(3).)
Paid by Medi-Cai in the amount of s
(a) I:
i $ [:1
Notice of this claim or action has been given to the State Director of Health Care Services under Welfare
and institutions Code section 14124.73. A copy oi the notice and proof of its delivery E]
is attached.
[:3 was tiled in this matter on (date):
(b) [:1 Notice of this claim or action has not been given to the State Director of Health Care Services
(Explain why notice has not been given In Attachment 13b(4). )
(c) [:1 In iuii satisfaction of its lien rights. Medi- Cal has agreed to accept reimbursement
in the amount cf: $
(Attach a copy of the iinai Medi~Cei demand letter or ietter agreement as Attachment 1312(4).)
(d) [I] Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and institutions Code
section 14124.76 and:
(l) L_—_I ls filing a motion seeking a reduction of the lien concurrently with this petition.
(ii) l3 Requests that the court reserve jurisdiction over this issue.
The amount of the lien in dispute is: $ ___________________
(5) E] (a) There are one or more statutory or contractual liens of medical service providers tor payment of medical
expenses. The total amount claimed under these liens is: $ . In iuii satisfaction
ot their lien claims. the lienholders have agreed to accept the total sum of: $
(Provide requested inforrnatlon on each Iienhoider and certain other medical service providers below.)
(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 petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any;
and the amount to be paid from the proceeds of the settlement or iudgment to each provider are as follows:
(I) (A) Provider (name):
(B) Address:
(:2)
~
(C) Amount charged: $
(D) Amount paid (whether or not by insurance) $< )
(E) Negotiated reduction. if any:
(F) Amount to be paid ircm proceeds of settlement or judgment $
(ii) (A) Provider (name):
(a) Address.
$-
(C) Amount charged:
(D) - Amount paid (whether or not by Insurance): $( .
t
)
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(E) Negotiated reduction. itany: $( )
(F) Amount to be paid from proceeds of settlement or judgment: $
A
[:3 Continued on Attachment 13b(5). (Provide information about additional providers in the above fonnet,
including providers paid or to he paid by petitioner for which reimbursement is requested in item i3bt 1) '
above. You may use form MC-350(A-13b(5)) for this purpose.)
'“°'°5°l“°i~t“‘"°'i 1' 2°"! PETITION TO APPROVECOMPROMISE OF DISPUTED CLAIIIII “WW”
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY '
(Miscellaneous)
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CASE NAME: on. autism
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IN THE MATTER OF ANAYA ALISA PRIMES
14. The claimant's attorneys 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 d. ment .
a. Total amount of attorney's fees ior which court approval ls requested: _
$ _
3 591,25
(l! fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request. including
a discussion oi applicable factors listed‘in rule 7. 955th) oi the Cal. Rules of Court. Respond to item 18a(2) on page 7 and
attach a copy 0t any written attorney fee agreement as Attachment 18a)
b. The following additional items of expense (other than medical expenses) have been Incurred or paid are reasonable, resulted
from the incident or accident. and should be paid out of claimant's share oi the proceeds of the settlement or judgment:
ite_m_s P e e Amounts
Filing Fee AA-Accident Attorneys, PLC s 435.00
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AA-Accident Attorneys, PLC
Accurint Search 1
s 200.00
$
$
$
$
$
$
$
$
$
[I] Continued on Attachment 14b. Total: $
15. Reimbursement of expenses paid by petitioner
a. III Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested.
b. II] Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses tor which
reimbursement is requested.
(1) [:1 Medical expenses listed in item 13: $
(2) [I] Attorney's fees included in the total tee amount shown in item 14a: $
(3) [:1
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Other expenses included in the total showu In item 14b: ~
m...
(Attach proofs o! the expenses incurred and payments made or obligations to pay Incurred, e.g., bills or invoices,
canceled checks, credit card statements, explanations of benefits from insurers, etc.)
$
$ 1::2: ‘
16. Net balance oi proceeds tor the claimant
The balance of the proceeds of the proposed settlement or judgment remaining for the ctalmant
after payment of all requested fees and expenses Is:
17. Summary
st 10,773,7§|
a. Gross amount of proceeds oi settlement or judgment for claimant:
15,000,00
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$ .
b. Medical expenses to be paid from proceeds of settlement
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or judgment: $ 0.00
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c. Attorney's tees to be paid from proceeds of settlement or
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judgment: ~
$ 3,591.25
d. Expenses (other than medical) to be paid item proceeds
of settlement or judgment. $
e. Total oi lees and expenses to be paid from proceeds oi settlement or judgment '
(adorn. (c). andrd» $<_____.;4_2_2_6L>
l. Balance oi proceeds oi settlement or judgment available tor claimant alter payment of all
tees and expenses (subtract (e) from (a)):
$
"WW"- M'Y "2m" PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM "8"“ ’°
OR PENDING ACTION OR DISPOSITION 0F PROCEEDS 0F
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
LexisNexisiE Automated California Judicial Carmel] Forms
CASE NAME:
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CA3: NUMBER:
so
“-
IN THE MATTER OF ANAYA ALISA PRIMES
18. Information about attorney representing or assisting petitioner
a. (1) [: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. (Go to item 19.)
(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 III
do not —
do 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 188, and complete items 18b.-18f.)
b. The attorney who has represented or assisted petitioner is (name): Paul E, Lee
(1) State Bar number. 172043
(2i Law tlrm: AA-Aocident Attorneys, PLC
<3) Address
4700 Teller Ave, 2nd Floor,
Newport Beach, CA 92660
c. -
(4) Telephone number:
The attorney
(949) 660-8753
has not | I has received attorney's fees or other compensation in addition to that requested in this
petition tor services provided In connection with the claim giving rise to this petition. (if you answered "has, "identify the person
who paid the fees or other compensation, the amounts paid, and the dates of payment):
Erom whom (names) -
Amounts Dates
ifl'EQVQGQU!
II] Continued on Attachment 180.
d. The attorney did not I: did 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 18d.)
e. The attorney [:1le not — is representing or employed by any other party or any insurance carrier involved in the
matter. (lf you answered "is, " Identity the party or carrier and explain the relationship in Attachment 18a. )
m
attomey- III
m
i. The does not does expect to receive attorney's tees or other compensation in addition to that
requested in this petition tor services provided in connection with the claim giving rise to this petition. (if you answered "does,"
identiijl the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates or payment):
FiO 0m m9 Amnia
M99096!“
I: Continued on Attachment 18f.
MNWR“ “WY " 2m" PETITION TO APPROVE COMPROMISE OF DISPUT ED CLAIM "l" 7°’ '°
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
{Miscellaneous}
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CASE NAME: Cheri NUMBER;
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19. Disposition of balance of proceeds of settlement or judgment
Petitioner requests that the balance oi the proceeds of the settlement or judgment be disbursed as follows:
a. [I] There is a guardianship ol the estate oi the minor or a conservatorship of the estateot the adult person with a
disability tiled in (name of court):
Case no.:
(1) 1:] $ of the proceeds in money or other property will be paid or delivered to
the guardian of the estate of the minor or the conservator oi the estate of the. conservatee. The money
or other property is specified in Attachment 19am.
<2) [Ii 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 pai
Preview
‘ OB..GINAL MC-350 ATTORNEY 0R PARTY WITHOUT ATTORNEY State Barnumber. and address): FOR COURT USE ONLY bNZnée. Paul E. Lee (Bar # 172 —~ AA-Accident Attorne s, PL 4700 Teller Ave, 2n Floor Newport Beach, CA 92660 TEEPHONE N0.: (949) 660-8753 FAX No. (Optlonal): (949) 660.8720 FEEED E-MAIL ADDRESS (Optional)! SAN MATEO COUNTY RENEE CRONIN, Petitioner ATTORNEY FOR (Name): SEP 1 0 2016 SUPERIOR coum OF CALIFORNIA, COUNTY OF SAN MATEO STREETADDRESS: 400 County Center Clarke e eriorCoun MAILING ADDRESS: 400 County Center 5y CITYANDZIP CODE: Redwood 94063 DEPI] INKEHK amen NAMEI Superior Court FAX CASE NAME; IN THE MATTER OF ANAYA ALISA PRIMES 1t c Iii t it e it PETITION TO APPROVE: l1] COMPROMISE OF DISPUTED CLAIM HEARING DATE: BY lII COMPROMISE 0F PENDING ACTION i OIQQA l $0 1:1 DISPOSITION 0F PROCEEDS OF JUDGMENT Minor III Person With a Disability NOTICE TO PETITIONERS: DEPT: PI TIME: 0110060,] l Except as noted below, you must use this form to request court approval of (1) the compromise of a disputed claim of a minor, lOlQ? (2) the compromise of a pending action or proceedlng in which a minor or a person with a disability (including a ocnservatee) is a party, or (3) the disposition of the proceeds of a judgment for a minor er person with a disability. (See Code Civ. Proc., § 372; Prob. Code, § 3600 et seq.) You and the minor or disabled person must attend the hearing on this petition unless the court for good cause dispenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or t3 examining physician, and other evidence relating to the merits of the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court may consider on an expedited basis without a hearing requests for approval of the compromises of certain claims and actions or the disposition of the proceeds of certain judgments. lf your claim, action, orjudgment qualifies for expedited consideration and you want to request it, you must use form MC-350EX for your request. See Cal. Rules of Court, rule 7.9505. 1, Petitioner (name): RENBE'CRONTN '2. Claimant (name): Anaya Alisa Primes a. Address: 1854 W. Bayshore Rd. #11, East Palo Alto, CA 94303 b. Date of birth: 7/21/2015 c. . Age: l d. Sex: Female e. Minor l__—_l Person withadisability 3. Relationship Petitioner's relationship to the claimant (check all applicable boxes): a. b. Parent III Guardian ad litem g. l:l Other relationship (specify:) c. [:Il Guardian d. III Conservator e. 1:] Disabled adult claimant is a petitioner. (See instructions for items 3e and 3f below.) f, [:1 Disabled adult claimant's express consent to the relief requested in this petition is provided on Attachment 8t. ' (if you checked item 3e or 3f, state facts on Attachment 3e or 3f showing that the claimant has capacity under Probate Code section 812 to petition or consent to a petition. Only an adult claimant who has sufficient capacity and who does not have a conservator of the estate may petition or consent to a petition. See Probate Code section 3613.) 4. Nature of claim The claim of the minor or adult person with a disability: a. Has not been filed in an action or proceeding. (Complete items 5-23.) b. III is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim. Name of court: Case no.: Trial date: (Complete items 5-23.) . Page 1 of 10 Cede ct Civil Procedure, § 372 et seq; Form Adopted tor PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Allemallve Mandatory Use _ Probate Coda. § 3500 el seq; Judicial Council of Caillctnia OR PENDING ACTION OR DISPOSITION OF PROCFF“e C“:- b5 3.1384. MC-350 lRev. January 1, 2011] 15-0LJ-01432 350. 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DI!’ PET . Irtscagov (Miscellaneous) Petition Filed Lexisi 18 'Forms 'llllllililillilllllllillillill l ' ' _i ~ t f mc-aso CASE NAME: 0AM nonsen- " IN THE MATTER OF ANAYA ALISA PRIMES p 4. Nature of claim The claim oi the minor or adult person with a disability: c. |:l Is the subject'of a pending action or proceeding that has been or will be reduced to a judgment tor the claimant against the defendants named below in the total amount (exclusive of interest and costs) oi (specify below): sl T Defendants memes! C] Additional defendants listed on Attachment _4. [:1 The Iudgment was tiled on (date): (Attach a copy of the (proposed) judgment as Attachment 4c end complete items 13-23.) 5. [Z] incident or accident The incident or accident occurred as tollowe: a. Date and time: July 14, 2015 at 3:40P.M.~ ' \ - b. Place: Burlingame, CA c. Parsons Involved (names): Renee Cronin (mother) and Fermin Alfredo Angulo 6.‘ [I] Continued on Attachment 5. Nature of incident or accident The |tacts events, and circumstances of the incident or accident are (describe): _ Renee Cronin was 7 months pregnant when shc was rcarcnded by the defendant Fermm A. Angulo, the imtiact caused Renee's vehicle to plunge forward and strike the vehicle in front of her. i l Cl Continued on Attachment 6. 7. I3] injuries Thel following injuries were sustained by the claimant as a result of the incident or accident (described; Renee Cromn (mother) was advrsed by paramedics to seek immediate care due to e stage of her pregnancy- i i [I] i Continued on Attachment 7. 8. [I] Trehtment The‘ cl lm rece e the l llow‘n care nd t ent for sc . in u : Renee mo er was 3cm tlrcR maimmgélfie'ii taken télhs>orlanriiletise1gr$eryfgaigditegs ‘lgllbglthitsifiilg'iiham Kim Thu, MD. who tiiYsogaz-ged coniiirmed her baby was alive. She was then held for observation and discharged with instructions to count the babies kicks and rctum if any pain pers sts. Ren'ee immediately began experiencing painiirl contractions a tow hours following her observation in the hospital. She was experiencing increasing and relentless pain due to the stress and force oi‘ impact. Renee suffered for three days following the accident and on July l7ih, 2015, as pain seized to subside, she returned to the hospital where she was immediately admitted due to preterm premature rupture of the fetal membranes (PPROM), She was immediately induced into pre-tenn labor. Ultimately she was given an emergency C-Section in cfi'orts to protect Renee and the baby. Her baby was bom 3 months premature. Anaya Primes was born 3 months premature and is currently under her pediatricians core to record the progress other gevclopeinglcrathedlatest report demonstrate that she in on course with her developcment compared with other children her ago had she been born on or sche e ue etc. ‘ E] Continued on Attachment a. WWW- January HO"! PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM PM“ 1° ' ' OR PENDING ACTION OR DISPOSITION 0F PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH ADISABILITY (Miscellaneous) LexisNexisiE Automated Cali/brutalJudtclat Council Forms .- i J‘ { CASE NAME: - cl»- numeric P IN THE MATTER OF ANAYA ALISA PRIMES 9. Extent of injuries and recovery (An original ora photocopy of ell doctors’ reports containing a diagnosis of and prognosis for the claimant's injuries. and e report oi‘ the claimant's present condition, must be attached to this petition as Attachment 9. A new report is not necessary so long es a previous report accurately describes the claimant's current condition.) a. The claimant hes recovered completely from the effects of the injuries described in Item 7. and there are no permanent inluries. b. [:3 The claimant has not recovered completely from the effects of the injuries described in Item 7, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries): I: Continued on Attachment 9b c. II] The claimant has not recovered completely from the effects of the lniuries described in Item 7, end the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries): III] Continued on Attachment 90. , 10. III Petitioner has made a careful and diligent inquiry and investigation to ascertain the facts relating to the incident or accident in which the claimant was Injured; the responsibility for the Incident or accident; and the nature, extent, and seriousness of the claimants injuries Petitioner fully understands that if the compromise proposed in this petition is approved by the court and ls consummated, the claimant will be forever barred from seeking any further recovery of compensation from the settling defendants named below even though the claimant's Injuries may in. the future appear to be more serious than they are now thought to be 11 . Amount and terms of settlement By way of settlement. the defendants named below have offered to pay the following sums to the claimant: a. The total amount offered by ell defendants named below is (specify): $I 15,000,0()I b. The defendants and amounts offered by each are as follows (specify): ' De names Fermin A. Angulo (Foremost Ins.) Am 15,000.00 69€969€9<69 III Defendants and amounts offered continued on Attachment 11. c. The terms of settlement are es follows (if the settlement ls lo be paid in installments, both the total amount end the present value of the settlement must be included): “:1 Continued on Attachment 11 Mc-WIRW-MWY 1-20'11 PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Pee-tom ‘ OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF ~ JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) Lexlcxls® Automated California Judicial Carma-it Forms CASE NAME: Cson. 1-) ‘UMBER’ l_. IN THE MATTER OF ANAYA ALISA PRIMES 12. E3 Settlement payments to others , a. 1:] No defendant named in item 11b 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. By way of settlement, one or more defendants named In item 11b have also offered to pay money to a person or persons other than claimant to settle claims arising out of the same incident or accident that resulted in the claimant's Injury. - (1) The total amount offered by all defendants to others (specify): $ 15, 000 00 (2) Petitioner —is not [:1 is a claimant against the recovery of the claimant (other than for reimbursement for expenses paid by petitioner and listed under item 15). - (it you answered”is, "explain in Attachment 12 the circumstances and the effect your claim has on the proposed com immise of the claim described in this petition) (3) Petitioner is not [:1 is a plaintiff in the same action with the claimant. (if you answered rs, "explain in Attachment 12 th'e circumstances and the effect your claim and its disposition has on the proposed compromise of the claim or action described in this petition ) (4) [I] Petitioner would receive money under the proposed settlement (6) The settlement payments are to be apportioned and distributed as follows: Oher Ia s r aI n nam s Amougts Renee Cronin 15,000.00 $698,“ E]Additional plaintiffs or claimants and amounts are listed on Attachment 12. (6) Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 12. 13. The claimant's medical expenses, including medical expenses paid by petitioner and Insurers, to be reimbursed from proceeds of settlement or judgment a. Totals . (1) Total medical expenses: s 335271400 [:I: (2) Total outstanding medical expenses to be paid from the proceeds: $ (3) Total out-of-pocket, co-payments. or deductible payments to be reimbursed from proceeds: $ b. Medical expenses were paid and are to be reimbursed from proceeds as follows: (1) [:1 Paid by petitioner In the amount of: $ II] Paid by private health insurance or a self-funded plan under. (2) (a) (b) I: I: An Employee Retirement Income Security Act (ERISA) Insured plan. An ERISA self-funded plan. (c) III A Non-ERISA insured plan. (d) III A Non-ERISA self-funded plan. -[:l‘No (e) Amount paid by plan: $ 335,714. 00 (i) Amount of reimbursement to the plan from proceeds of settlement or judgment: (i) reimbursement is requested by the plan. ~ MWIRW- 4W 1.20111 (It) , Reimbursement Is to be made to the plan and: (A) (B) (c) :1 1::1 [:1 There is a contractual reduction of $( There is a negotiated rechrctlon of $ ( No reduction has been agreed to, for a total reimbursement to the plan In the amount of: PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION 0F PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) > ) ) $ ' :1 ‘ "some LexisNexls® Automated California Judicial Council Form: I ‘ ' i“ ' mc-aso CASE NAME: oAse uuuesm l- IN THE MATTER OF ANAYA ALISA PRIMES 13. The claimant's medical expenses. Including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment b Medical expenses were paid and are to be reimbursed from proceeds as follows: (3) (4) [I II] ' Paid by Medicare in the amount of: lees the statutory reduction In the amount of: $ t for a total reimbursement to Medicare In the amount of: $ ) (Attach a copy ofthe iinai Medicare demand letter or ietter agreement as Attachment i3b(3).) Paid by Medi-Cai in the amount of s (a) I: i $ [:1 Notice of this claim or action has been given to the State Director of Health Care Services under Welfare and institutions Code section 14124.73. A copy oi the notice and proof of its delivery E] is attached. [:3 was tiled in this matter on (date): (b) [:1 Notice of this claim or action has not been given to the State Director of Health Care Services (Explain why notice has not been given In Attachment 13b(4). ) (c) [:1 In iuii satisfaction of its lien rights. Medi- Cal has agreed to accept reimbursement in the amount cf: $ (Attach a copy of the iinai Medi~Cei demand letter or ietter agreement as Attachment 1312(4).) (d) [I] Petitioner is entitled to a reduction of the Medi-Cal lien under Welfare and institutions Code section 14124.76 and: (l) L_—_I ls filing a motion seeking a reduction of the lien concurrently with this petition. (ii) l3 Requests that the court reserve jurisdiction over this issue. The amount of the lien in dispute is: $ ___________________ (5) E] (a) There are one or more statutory or contractual liens of medical service providers tor payment of medical expenses. The total amount claimed under these liens is: $ . In iuii satisfaction ot their lien claims. the lienholders have agreed to accept the total sum of: $ (Provide requested inforrnatlon on each Iienhoider and certain other medical service providers below.) (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 petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reduction of charges, if any; and the amount to be paid from the proceeds of the settlement or iudgment to each provider are as follows: (I) (A) Provider (name): (B) Address: (:2) ~ (C) Amount charged: $ (D) Amount paid (whether or not by insurance) $< ) (E) Negotiated reduction. if any: (F) Amount to be paid ircm proceeds of settlement or judgment $ (ii) (A) Provider (name): (a) Address. $- (C) Amount charged: (D) - Amount paid (whether or not by Insurance): $( . t ) ’ (E) Negotiated reduction. itany: $( ) (F) Amount to be paid from proceeds of settlement or judgment: $ A [:3 Continued on Attachment 13b(5). (Provide information about additional providers in the above fonnet, including providers paid or to he paid by petitioner for which reimbursement is requested in item i3bt 1) ' above. You may use form MC-350(A-13b(5)) for this purpose.) '“°'°5°l“°i~t“‘"°'i 1' 2°"! PETITION TO APPROVECOMPROMISE OF DISPUTED CLAIIIII “WW” OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY ' (Miscellaneous) LexisNexIs® A utomaied California Judicial Council Forms ~ f. J ' - rec-go . CASE NAME: on. autism T‘ IN THE MATTER OF ANAYA ALISA PRIMES 14. The claimant's attorneys 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 d. ment . a. Total amount of attorney's fees ior which court approval ls requested: _ $ _ 3 591,25 (l! fees are requested, attach as Attachment 14a, a declaration from the attorney explaining the basis for the request. including a discussion oi applicable factors listed‘in rule 7. 955th) oi the Cal. Rules of Court. Respond to item 18a(2) on page 7 and attach a copy 0t any written attorney fee agreement as Attachment 18a) b. The following additional items of expense (other than medical expenses) have been Incurred or paid are reasonable, resulted from the incident or accident. and should be paid out of claimant's share oi the proceeds of the settlement or judgment: ite_m_s P e e Amounts Filing Fee AA-Accident Attorneys, PLC s 435.00 " , AA-Accident Attorneys, PLC Accurint Search 1 s 200.00 $ $ $ $ $ $ $ $ $ [I] Continued on Attachment 14b. Total: $ 15. Reimbursement of expenses paid by petitioner a. III Petitioner has paid none of the claimant's expenses listed in items 13 and 14 for which reimbursement is requested. b. II] Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's expenses tor which reimbursement is requested. (1) [:1 Medical expenses listed in item 13: $ (2) [I] Attorney's fees included in the total tee amount shown in item 14a: $ (3) [:1 ' ' Other expenses included in the total showu In item 14b: ~ m... (Attach proofs o! the expenses incurred and payments made or obligations to pay Incurred, e.g., bills or invoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) $ $ 1::2: ‘ 16. Net balance oi proceeds tor the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the ctalmant after payment of all requested fees and expenses Is: 17. Summary st 10,773,7§| a. Gross amount of proceeds oi settlement or judgment for claimant: 15,000,00 ~ - $ . b. Medical expenses to be paid from proceeds of settlement _ or judgment: $ 0.00 “M ' c. Attorney's tees to be paid from proceeds of settlement or ' judgment: ~ $ 3,591.25 d. Expenses (other than medical) to be paid item proceeds of settlement or judgment. $ e. Total oi lees and expenses to be paid from proceeds oi settlement or judgment ' (adorn. (c). andrd» $<_____.;4_2_2_6L> l. Balance oi proceeds oi settlement or judgment available tor claimant alter payment of all tees and expenses (subtract (e) from (a)): $ "WW"- M'Y "2m" PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM "8"“ ’° OR PENDING ACTION OR DISPOSITION 0F PROCEEDS 0F JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) LexisNexisiE Automated California Judicial Carmel] Forms CASE NAME: I A I CA3: NUMBER: so “- IN THE MATTER OF ANAYA ALISA PRIMES 18. Information about attorney representing or assisting petitioner a. (1) [: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. (Go to item 19.) (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 III do not — do 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 188, and complete items 18b.-18f.) b. The attorney who has represented or assisted petitioner is (name): Paul E, Lee (1) State Bar number. 172043 (2i Law tlrm: AA-Aocident Attorneys, PLC <3) Address 4700 Teller Ave, 2nd Floor, Newport Beach, CA 92660 c. - (4) Telephone number: The attorney (949) 660-8753 has not | I has received attorney's fees or other compensation in addition to that requested in this petition tor services provided In connection with the claim giving rise to this petition. (if you answered "has, "identify the person who paid the fees or other compensation, the amounts paid, and the dates of payment): Erom whom (names) - Amounts Dates ifl'EQVQGQU! II] Continued on Attachment 180. d. The attorney did not I: did 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 18d.) e. The attorney [:1le not — is representing or employed by any other party or any insurance carrier involved in the matter. (lf you answered "is, " Identity the party or carrier and explain the relationship in Attachment 18a. ) m attomey- III m i. The does not does expect to receive attorney's tees or other compensation in addition to that requested in this petition tor services provided in connection with the claim giving rise to this petition. (if you answered "does," identiijl the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates or payment): FiO 0m m9 Amnia M99096!“ I: Continued on Attachment 18f. MNWR“ “WY " 2m" PETITION TO APPROVE COMPROMISE OF DISPUT ED CLAIM "l" 7°’ '° OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY {Miscellaneous} LexisNexls® Automated California Judicial Council Farms (" ( mc-aso . _ CASE NAME: Cheri NUMBER; "' IN THE MATTER OF ANAYA ALISA PRIMES 19. Disposition of balance of proceeds of settlement or judgment Petitioner requests that the balance oi the proceeds of the settlement or judgment be disbursed as follows: a. [I] There is a guardianship ol the estate oi the minor or a conservatorship of the estateot the adult person with a disability tiled in (name of court): Case no.: (1) 1:] $ of the proceeds in money or other property will be paid or delivered to the guardian of the estate of the minor or the conservator oi the estate of the. conservatee. The money or other property is specified in Attachment 19am. <2) [Ii 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 pai