DocuSign Envelope ID: CF0A36B8-C141-482B-8201-256CEDDAD221

GOVERNMENT EMPLOYEES INSURANCE COMPANIES

Claim Number

0557461720101022

Policy Number 4430728685

Date of Loss 10/01/2016

Vehicle Theft Questionnaire

(Please complete even if vehicle is recovered)

Stanley J Caterbone
Name of Insured/Owner: _____________________________________________
Date of Birth: 07/15/1958
________________
1250 Fremont St , Lancaster, PA 17603-6812
Residence Address: ___________________________________________________________________________
Street

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City

State

Zip Code

(717) 826-5354
Telephone Number: Home: ___________________________
Business: _____________________________
10
How long have you been living at the above residence? _________________years
220 Stone Hill Road, Conestoga, PA 17538
Previous Residence Address: ____________________________________________________________________
Street

City

State

Zip Code

Disabled - SS Disability for Symptoms and Illnesses for U.S. Sponsored Mind Control since 2008
Employer Name: ______________________________________________________________________________
Address: __________________________________________________________________________________________________
Street

City

State

Zip Code

Occupation/Position: ________________________________________________ Length of Service: ___________

200-46-0959
PA
18195782
Social Security #: ________________
Driver's License #: ___________________________________
State:_____
Marital Status: Single
Married
Divorced
Separated
Widow
Spouse's Name: ____________________________________________ Date of Birth: ____________________
A
Address: (If different from residence address) __________________________________________________________
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Street

City

State

Zip Code

Telephone Number: Home: ___________________________ Business: ___________________________

Employer: ________________________________________________________________________________
Address: _________________________________________________________________________________

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Street

City

State

Zip Code

Occupation: _______________________________________________________________________________
Social Security #: _________________ Driver's License #: ______________________________ State:_____

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Others Residing In Household:

NAME/RELATION

SEX

Male
Male
Male
Male

DATE OF BIRTH

DRIVERS LICENSE NUMBER

Female
Female
Female
Female

Other Vehicles Located At Residence Address:

YEAR

MAKE

MODEL

PLATE NO.

INSURANCE COMPANY

K M 8 S C 7 3 D 9 4 U 7 0 9 9 6 4
__________________________________
Vehicle Identification Number (VIN):
PA
KBC7596/KBC9575
94,000
State: ______________
License Plate Number: ______________________________
Mileage _______________
Maroon / Burgundy
TRAILER HITCH
2004 Make: ______________
HYUNDAI
SNTFE AWD
Year: _____
Model: ___________________
Color: __________
Special Packages: __________
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Please check any vehicle options that apply:

Transmission

Power

Overdrive

4 Wheel Drive
Positraction

Power Steering

AM/FM Stereo Radio

Power Brakes

CD Player

Power Windows

Power Locks

Transmission Type

CD Changer/Stacker

Power Driver Seat

Automatic Transmission

Power Passenger Seat

6 Speed Transmission
5 Speed Transmission

Radio

3 Speed Transmission

C-116 PA (03-14) NS

Cloth Seats
Leather Seats

Reclining/Lounge Seats

Premium Radio

Bucket Seats

Satellite Radio

Heated Seats

Steering Wheel Touch Controls

Rear Heated Seats

Power Antenna

Auxiliary Audio Connection

3rd Row Seat

Power Mirrors

Equalizer

Power Third Seat

Power Trunk/Gate
Release

4 Speed Transmission

Seating

Power Adjustable Pedals

DocuSign Envelope ID: CF0A36B8-C141-482B-8201-256CEDDAD221

Decor/Convenience

Roof

Safety/Brakes

Wheels

Air Conditioning

Electric Glass Roof

Drivers Side Air Bag

Climate Control

Electric Steel Roof

Passenger Air Bag

Rear Defogger

Skyview Roof

Tilt Wheel

Dual Power Sunroof

Auto Level

Aluminum/Alloy Wheels

Exterior/Paint/glass

Chrome Wheels

Luggage/Roof Rack

20" Or Larger Wheels

Exterior Woodgrain

Deluxe Wheel Covers

Rear Window Wiper

Full Wheel Covers

Alarm

Two Tone Paint

Spoke Aluminum Wheels

Front Side Impact Air

Bags
Rear Side Impact Air
Bags

Telescopic Wheel

Manual Steel Roof

Cruise Control

Manual Glass Roof

Keyless Entry

Flip Roof

Night Vision

Three Stage Paint

Styled Steel Wheels

Console/Storage

T-top/Panel

Intelligent Cruise

Clearcoat Paint

Wire Wheels

Metallic Paint

Wire Wheel Covers

Rear Spoiler

Rally Wheels
Locking Wheels

Overhead Console
Entertainment
Center

Navigation System
Communications
System

Glass T-tops/Panel
Power Convertible
Top
Detachable Roof

Head/Curtain Air Bags

Parking Sensors
Parking Sensors
W/Equip

Vinyl Covered Roof

Anti-lock Brakes (4)

Fog Lamps

Anti-lock Brakes (2)

Tinted Glass

Locking Wheel Covers

Privacy Glass

Additional Items not listed:

Heads Up Display

Cabriolet Roof

4-wheel Disc Brakes

Wood Interior Trim

Landau Roof

Electronic
Instrumentation

Roll Bar

Body Side Moldings

Padded Landau Roof

Traction Control

Dual Mirrors

Padded Vinyl Roof

Stability Control

On Board Computer

Heated Mirrors

Message Center

Headlamp Washers
Signal Integrated
Mirrors

Memory Package
Remote Starter
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Please list any customizations or modifications to the vehicle. This should include any non-factory installed items:
Customization (Please include brand name and model information)
Date Installed
Value

TRAILER HITCH AND BIKE RACK

September 25, 2016

$300.00

$6,072.00
09/17/2016
Purchase/Lease Date: _______________
NEW
USED
Purchase Price: $____________
(717) 391-6757
Seller's Name: __________________________________
Telephone Number: ________________________
Barry Miller Quality Cars
1258 Manheim Pike, Lancaster, PA 17601
Address: ________________________________________________________________________________
NO
Trade In?
YES Value of Trade In: $_________________________
Lienholder/Leasing Co. Name: ___________________________________________________________________
Address: ________________________________________________________________________________
Street

City

State

Zip Code

Telephone Number: ___________________________

Account Number: _______________________________ Down Payment: __________________________
Last Payment: $_________________________________ Date: __________________________________
Has vehicle ever been repossessed?
NO
YES
Is the vehicle currently under a repossession order?
NO
YES
Are payments up to date?
YES
NO
Lienholder notified of THEFT?
YES
NO
Do you have any other outstanding loans on this vehicle or its equipment?
NO
YES
If yes, with whom? __________________________ Amount? $_______
Stanley J Caterbone
Owner(s) as shown on title: _________________________________________________________________
Name of Service Station: ____________________________ Telephone Number: ________________________
Address of Service Station: _____________________________________________________________________
Street

City

State

Zip Code

09/21/2016
Date of Last Service: _____________________
Work Performed: __________________________________
List any work performed since purchase other than tune-up, oil, grease:___________________________________
State Inspection/Oil Change
____________________________________________________________________________________________
September 21, 2016
When & Where Repaired: ______________________________________________________________________

C-116 PA (03-14) NS

DocuSign Envelope ID: CF0A36B8-C141-482B-8201-256CEDDAD221

NO
Has vehicle been involved in any losses since its purchase?
YES
Date of Loss: _____________________ Location: ________________________________________________
Type of Loss: ________________________________________________________________________________
Damages/Area: _______________________________________________________________________________
Amount: $____________________________________ Repairs Completed?
NO
YES
Insurance Company: ___________________________________________________________________________
D
Telephone Number: _______________________
A Repair Shop Name: _______________________________
M
Address: ________________________________________________________________________________
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Zip Code

Was there any unrepaired body or mechanical damage on the vehicle prior to the theft?
NO
YES
If "YES" list damages: ____________________________________________________________________________
Stan J. Caterbone
Who had custody of vehicle at the time of the theft? __________________________________________________
Lot on North Mary Street 1st parking space closest to N. Mary Street, Lancaster City, PA
Exact location of theft: __________________________________________________________________________
When to get one drink at Hildeys Bar on the corner of N. Mary and East Federick
Reason car at location: _________________________________________________________________________
10/01/2016
01:40 AM
Date and time vehicle last seen before theft: _____________________
____________
A.M.
P.M.
02:10 AM
10/01/2016
Date and time vehicle discovered missing: _____________________
____________
A.M.
P.M.
2
How many keys were you provided at the time you purchased the vehicle? ______________
Did you have any additional keys made for this vehicle? NO
YES If yes, how many?_______
Are there any keys missing?
YES When did you notice these keys missing?____________________
NO
Were there any keys in or upon the vehicle at the time of the theft? NO
YES Where?_________________
Does the vehicle have either a factory or aftermarket remote starter? NO
YES
Was the vehicle locked?
NO YES Alarm in use?
NO YES
N/A
Was vehicle parked in a tow away zone?
NO
YES
YES If Yes, did police tow it? NO
Are there any outstanding parking tickets? NO
YES
Briefly describe any vehicle usage 24 hours prior to theft, up to and including a description of the loss:

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I am a federal whistleblower and involved in litigation in the following cases: 1.J.C. No. 03-16-90005 Office of the Circuit Executive, United States Third Circuit Court of Appeals - COMPLAINT OF JUDICIALMISCONDUCT OR DISABILITY re 153400 and 16-1149; 03-16-900046 re ALL FEDERAL LITIGATION TO DATE
2.U.S.C.A. Third Circuit Court of Appeals Case No. 16-3284 Chapter 11 Bankruptcy Appeal; Case No. 16-1149 MOVANT for Lisa Michelle Lambert;15-3400 MOVANT for Lisa Michelle Lambert;; 16-1001; 07-4474
3.U.S. District Court Eastern District of PA Case No. 16-4641 Petition for Habeus Corpus; Case No. 16-cv-4014 2005 Conitued Case; Case No. 16-cv-49 Chapter 11 Appeal; 15-03984; 14-02559 MOVANT for Lisa Michelle Lambert; 05-2288; 064650, 08-02982;
4.U.S. District Court Middle District of PA Case No. 16-cv-1751 PETITION FOR HABEUS CORPUS
5.Commonwealth of Pennsylvania Judicial Conduct Board Case No. 2016-462 Complaint against Lancaster County Court of Common Pleas Judge Leonard Brown III
6.Pennsylvania Supreme Court Case No. 495 MAL 2016 Caterbone v. Lancaster County Residents; Case No. 496 MAL 2016 Caterbone v. Lancaster City Police Dept.; Case No. 353 MT 2016; 354 MT 2016; 108 MM 2016 Amicus for Kathleen
Kane
7.Superior Court of Pennsylvania Case No. 16-MD-1219 Preliminary Emergency Injunction; AMICUS for Kathleen Kane Case No. 1164 EDA 2016; Case No. 1561 MDA 2015; 1519 MDA 2015; 16-1219 Preliminary Injunction Case of 2016
8.Lancaster County Court of Common Pleas Case No. 08-13373; 15-10167; 06-03349, CI-06-03401
9. U.S. Bankruptcy Court for The Eastern District of Pennsylvania Case No. 16-10157
On Wednesday September 28, 2016 I had my computer and briefcase stolen. While I was at the bar on the night of the theft I was assaulted by Mr. John Keener, who refused to let me leave the bar. I had to take his picture in order to leave the
establishment and used my Yellow Cab App on my smartphone to summon a cab. He then followed me outside to again assault me, however, my cab arrived just in time.
I suspect that since I had a handicap placard that the parking spaces were filled prior to my arrival. This happens all the time and is called COMMUNITY STALKING.

NO - I CANNOT HAVE ANY CONTACT WITH POLICE DUE TO PRIOR ABUSE BY POLICE, SEE UPLOAD NO. 2
Who notified police? ____________________________________________________________________________

Precinct: ________________________________
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Case Number: _________________

Agency/Department: _______________________________

Officer: __________________________

Date and time theft reported: _____________________

Time: _________

ARE YOU RENTING A CAR DUE TO THE THEFT?

NO

A.M.

YES

Badge Number: _____________

P.M.

By Phone

In Person

If "YES", please provide:

IF YOU PROVIDE
Rental Co.: ____________________________________
Telephone Number: __________________________
NO
WAS THE STOLEN VEHICLE LOANED OR BORROWED?
YES

I If "YES", complete this section:

N
Name: ____________________________________________ Telephone Number: ______________________
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O Address: ____________________________________________________________________________________
Street
City
State
Zip Code
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YES
NO
A Relationship: __________________ Purpose: ______________________ Does borrower own a vehicle?
T WAS VEHICLE PARKED IN PUBLIC GARAGE OR PARKING LOT? NO
YES If "YES", complete this section.
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Name
of
parking
lot/garage:
_________________________________________________________________________
O
N Address: ________________________________________________________________________________________

Insurance Company of garage:_______________________________________________________________________

Who parked the car? __________________________________
Who was given possession of keys Attendant: __________________________________________________________
C-116 PA (03-14) NS

DocuSign Envelope ID: CF0A36B8-C141-482B-8201-256CEDDAD221

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NO
Have you or any member of your family ever had a vehicle stolen?
YES
If yes, Date: _____________________ Location: _________________ Insurance Company: __________________
If recovered, its condition: _______________________________________________________________________

Do you have any other Theft Insurance on stolen vehicle?

NO
YES ____________________________
I
Is
the
vehicle
that
is
reported
stolen
legally
registered
and
titled
at
the
Department
of Motor Vehicles that issued the
N
F title and plates?
YES
NO
O
Name and contact information of suspected thief:___________________________________________________
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RECOVERY
Date: ______________ Time:
A.M.
P.M. Place:____________________________________
Recovery Reported to GEICO?
NO
YES Date: _____________________
Is vehicle drivable?
YES
NO Who recovered the vehicle? ____________________________________
Arrests made?
NO
YES Name and Address: ____________________________________________
Damage due to theft?
NO
YES Describe: _______________________________________________
Was vehicle viewed by policyholder?
NO
YES Where: _____________________________________________
Vehicle located at the present time:________________________________________________________________
Telephone Number: _______________________________
IF THERE WERE ANY PERSONAL ITEMS IN YOUR VEHICLE THAT REMAIN UNRECOVERED AND YOUR
POLICY PROVIDES COVERAGE FOR PERSONAL EFFECTS, PLEASE COMPLETE THIS SECTION:
Please list items separately in the spaces provided below:

Value of each item:

See upload no. 2

TOTAL VALUE OF UNRECOVERED ITEMS (LIMIT OF $200):

NOTE: LOSS TO ANY TAPE, WIRE, RECORD DISC OR OTHER MEDIUM FOR USE WITH A DEVICE DESIGNED FOR THE RECORDING
AND/OR REPRODUCTION OF SOUND IS NOT COVERED. OTHER EXCLUSIONS MAY APPLY. PLEASE REFER TO YOUR CONTRACT.

If the identity of the person or persons responsible for the theft of this vehicle is established, are you willing to
NO
prosecute that person or persons?
YES

Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any
false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and
payment of a fine of up to $15,000.
I swear that the information contained in the prior four
(4) pages are true and correct to the best of my knowledge.
Stanley J Caterbone
Name: _______________________________________
1250 Fremont St , Lancaster, PA 17603-6812
Address: _____________________________________

Signature: ____________________________________
10/03/2016
Date: ________________________________________

C-116 PA (03-14) NS