Preview
FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018
I
Officeof theNew YorkCity Comptroller
-".', (i-„=7, -.'I,'(-
New York Comptroller 1 CentreStreet
City
ScottM. Stringer New York,NY 10007
' pgl~ah Form Version: NYC-COMPT-BLA-Pll-B
Personal Injury Claim Form
filed
Electronically claimsmust be filedat theNYC Comptroller's Website.If yourclaimis notresolved
within 1 yearand 90 days from thedate ofoccurrence you must startlegal
action topreserve your rights.
l am filing:F On behalf ofmyself. (¾ Attorneyis filing.
On behalf ofsomeone else. If on someoneelse's . Attorney Information (ifclaimant is represented by attorney)
(
behalf,please providethe followinginformation.
Firm or Last Name: Yudin and Yudin, PLLC
Last Name.
--- Firm orFirstName: Yudin and Yudin, PLLC
First
Name:
Address: 370 Seventh Avenue, Suite720
Relationshipto
the claimant: Address 2:
- - City: New York
. State: NEW YORK
Claimant Information
Zip Code: 10001
*LastName: Olivencia
Tax ID: 13-375099
*First
Name: Mabel
Phone #: 2129497979
Address: 2440 Prospect Ave, Apt 2
*Email Address: ryudin@yudinlawfirm.com
Address 2:
*Retype Email
City: Bron× ryudin@yudinlawfirm.com
Address:
State: NEW YORK
The time and place where the claimarose
Zip Code: 10458
*Date ofIncident: 06/17/2014 Format: MM/DD/YYYY
Country: USA -
__ __.. ______
of Format: HH:MM
Time Incident: 5:45 PM AM/PM
Date of Birth: Format: MM/DD/YYYY - -.-- -- ..
*Location of On the sidewalk in front
of thepremises
Soc. Sec. # Incident: Authority"
known as "AutoSales locatedat
HICN: 682 E. Fordham Road Bronx, NY (which is also
(Medicare #) listedas 680E. Fordham Road) near the
corner ofE. Fordham Road and Cambreleng
Date ofDeath: Format: MM/DD/YYYY
Avenue Bronx,NY. See photo attached for
Phone: location.
*EmailAddress: ryudin@yudinfawfirm.com
"Retype Email
ryudin@yudinlawfirm,com
Address:
Occupation:
CityEmployee? F Yes t No C NA
Gender F Male F Female C Other
Address: 682 E. Fordham Road
Address 2:
City: Bronx
State: NEW YORK
Borough: BRONX
'Denotes required A Claimant
fields. OR an Attorney Email Addressis required,
FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018
... Officeofthe New YorkCity Comptroller
1 CentreStreet
'z, New York CityComptroller
s>>~q."'.iz'E New York,NY 10007
ScottM. Stringer
r'~~
"~i~
*Manner inwhich The claim arosewhen claimant,Mabel tripped
Olivencia, and fell
due toan open and unguarded rectangular metal
claimarose: hole on thesidewalk near thecorner of 682 E. Fordham Road and Cambreleng Avenue (premises known as "Auto
Authority"
as she was
Sales Authority") walking on E. Fordham Road, thesame forming a trap,
and/or a hazard.The said
accident was caused by the negligence,carelessnessand recklessnessof theCITY OF NEW YORK, it agents,
employees, servants and/or independent contractors in permitting,
allowing and/or creatingthedangerous
condition at the
as aforestated said in causing,
location; permittingand allowingthe sidewalkat the
aforementioned locationto be, become and remain in an unsafecondition,in a state
of disrepair,
withan
unguarded metal hole,the same forming a trapand nuisance and constituting a danger,menace, and hazardto
persons lawfullyand properlywalking near the cornerof E. Fordham Road and Cambreleng Avenue Bronx, NY,in
frontof theaforementioned location,includingmore this
particularly claimant,Mabel Olivencia;in allowingthe
aforementioned dangerous and hazardous condition toexistfora long and unreasonable length of timewithout
repairingsame aftertheCityknew or should have known of the existenceofsuch condition;in failing
to warn;in
removing a light
pole or othersignor fixtureand to
failing properlycover theopening in thesidewalk,and in
to
failing exercisedue and proper care, prior
all after writtennotice,actualnotice and constructivenoticeof said
dangerous conditioncomplained of.
'Denotes required field.
FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018
..·· Officeof theNew York City Comptroller
..,
s.,
$';-'Gjx'~
Q I I'
-",.': 1 CentreStreet
New York CityComptroller
New York, NY10007
ScottM. Stringer
The items of medical
Pain, suffering, expenses and loss of wages,
including,but not limitedtolower back leg injuries
left
injuries,
damage or injuriesand leftelbow extent
injuries,the of whichare currentlyunknown with accompanying limitationof motionand
claimed are function;all to
her damages in thesum of ONE MILLION DOLLARS ($1,000,000.00).
Total amount claimedis
(include dollar 51,000,000.00.
amounts):
I
I
I
I
I
I
I
FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018
s¶tŸ Å •., Officeof theNew York City Comptroller
1 CentreStreet
.-„i',. . . New York CityComptroller
",4.= New York, NY 10007
-%.)~".4:, Scott M. Stringer
', C ..P,~';
Medical Information Witness 1 Information
---___._ ..
1st Treatment Date: 6/17/2014 Format: MM/DD/YYYY LastName:
Hospital/Name: St. BarnabasHospita FirstName:
Address: Add ress
Address 2: Address 2:
City: Bron× City:
State: NEW YORK State: NEW YORK
Zip Code: Zip Code:
Date Treated in
06/17/2014
Format WWW Witness 2 Information
Emergency Room:
(•'
Was claimant taken to hospitalby foYes C No F NA LastName:
an ambulance?
FirstName:
Employment Information (if
claiming lostwages) Address
Employer's Name: Address 2:
Address City:
_ __.-
Address 2: State: NEW YORK
City: Zip Code:
State: NEW YORK .
Witness 3 Information
Zip Code:
LastName:
Work Days Lost:
FirstName:
Amount Earned _...
Weekly: Address
Address 2:
Treating Physician Information
City:
LastName:
State: NEW YORK
FirstName:
Zip Code:
Address:
Witness 4 Information
Address 2:
City; LastName:
State: NEW YORK FirstName:
Zip Code: Add ress
Address 2:
City:
State: NEW YORK
Zip Code:
FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018
Officeofthe New YorkCity Comptroller
1 CentreStreet
.~~~;,1~~«'r".
Preview
FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018 I Officeof theNew YorkCity Comptroller -".', (i-„=7, -.'I,'(- New York Comptroller 1 CentreStreet City ScottM. Stringer New York,NY 10007 ' pgl~ah Form Version: NYC-COMPT-BLA-Pll-B Personal Injury Claim Form filed Electronically claimsmust be filedat theNYC Comptroller's Website.If yourclaimis notresolved within 1 yearand 90 days from thedate ofoccurrence you must startlegal action topreserve your rights. l am filing:F On behalf ofmyself. (¾ Attorneyis filing. On behalf ofsomeone else. If on someoneelse's . Attorney Information (ifclaimant is represented by attorney) ( behalf,please providethe followinginformation. Firm or Last Name: Yudin and Yudin, PLLC Last Name. --- Firm orFirstName: Yudin and Yudin, PLLC First Name: Address: 370 Seventh Avenue, Suite720 Relationshipto the claimant: Address 2: - - City: New York . State: NEW YORK Claimant Information Zip Code: 10001 *LastName: Olivencia Tax ID: 13-375099 *First Name: Mabel Phone #: 2129497979 Address: 2440 Prospect Ave, Apt 2 *Email Address: ryudin@yudinlawfirm.com Address 2: *Retype Email City: Bron× ryudin@yudinlawfirm.com Address: State: NEW YORK The time and place where the claimarose Zip Code: 10458 *Date ofIncident: 06/17/2014 Format: MM/DD/YYYY Country: USA - __ __.. ______ of Format: HH:MM Time Incident: 5:45 PM AM/PM Date of Birth: Format: MM/DD/YYYY - -.-- -- .. *Location of On the sidewalk in front of thepremises Soc. Sec. # Incident: Authority" known as "AutoSales locatedat HICN: 682 E. Fordham Road Bronx, NY (which is also (Medicare #) listedas 680E. Fordham Road) near the corner ofE. Fordham Road and Cambreleng Date ofDeath: Format: MM/DD/YYYY Avenue Bronx,NY. See photo attached for Phone: location. *EmailAddress: ryudin@yudinfawfirm.com "Retype Email ryudin@yudinlawfirm,com Address: Occupation: CityEmployee? F Yes t No C NA Gender F Male F Female C Other Address: 682 E. Fordham Road Address 2: City: Bronx State: NEW YORK Borough: BRONX 'Denotes required A Claimant fields. OR an Attorney Email Addressis required, FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018 ... Officeofthe New YorkCity Comptroller 1 CentreStreet 'z, New York CityComptroller s>>~q."'.iz'E New York,NY 10007 ScottM. Stringer r'~~ "~i~ *Manner inwhich The claim arosewhen claimant,Mabel tripped Olivencia, and fell due toan open and unguarded rectangular metal claimarose: hole on thesidewalk near thecorner of 682 E. Fordham Road and Cambreleng Avenue (premises known as "Auto Authority" as she was Sales Authority") walking on E. Fordham Road, thesame forming a trap, and/or a hazard.The said accident was caused by the negligence,carelessnessand recklessnessof theCITY OF NEW YORK, it agents, employees, servants and/or independent contractors in permitting, allowing and/or creatingthedangerous condition at the as aforestated said in causing, location; permittingand allowingthe sidewalkat the aforementioned locationto be, become and remain in an unsafecondition,in a state of disrepair, withan unguarded metal hole,the same forming a trapand nuisance and constituting a danger,menace, and hazardto persons lawfullyand properlywalking near the cornerof E. Fordham Road and Cambreleng Avenue Bronx, NY,in frontof theaforementioned location,includingmore this particularly claimant,Mabel Olivencia;in allowingthe aforementioned dangerous and hazardous condition toexistfora long and unreasonable length of timewithout repairingsame aftertheCityknew or should have known of the existenceofsuch condition;in failing to warn;in removing a light pole or othersignor fixtureand to failing properlycover theopening in thesidewalk,and in to failing exercisedue and proper care, prior all after writtennotice,actualnotice and constructivenoticeof said dangerous conditioncomplained of. 'Denotes required field. FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018 ..·· Officeof theNew York City Comptroller .., s., $';-'Gjx'~ Q I I' -",.': 1 CentreStreet New York CityComptroller New York, NY10007 ScottM. Stringer The items of medical Pain, suffering, expenses and loss of wages, including,but not limitedtolower back leg injuries left injuries, damage or injuriesand leftelbow extent injuries,the of whichare currentlyunknown with accompanying limitationof motionand claimed are function;all to her damages in thesum of ONE MILLION DOLLARS ($1,000,000.00). Total amount claimedis (include dollar 51,000,000.00. amounts): I I I I I I I FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018 s¶tŸ Å •., Officeof theNew York City Comptroller 1 CentreStreet .-„i',. . . New York CityComptroller ",4.= New York, NY 10007 -%.)~".4:, Scott M. Stringer ', C ..P,~'; Medical Information Witness 1 Information ---___._ .. 1st Treatment Date: 6/17/2014 Format: MM/DD/YYYY LastName: Hospital/Name: St. BarnabasHospita FirstName: Address: Add ress Address 2: Address 2: City: Bron× City: State: NEW YORK State: NEW YORK Zip Code: Zip Code: Date Treated in 06/17/2014 Format WWW Witness 2 Information Emergency Room: (•' Was claimant taken to hospitalby foYes C No F NA LastName: an ambulance? FirstName: Employment Information (if claiming lostwages) Address Employer's Name: Address 2: Address City: _ __.- Address 2: State: NEW YORK City: Zip Code: State: NEW YORK . Witness 3 Information Zip Code: LastName: Work Days Lost: FirstName: Amount Earned _... Weekly: Address Address 2: Treating Physician Information City: LastName: State: NEW YORK FirstName: Zip Code: Address: Witness 4 Information Address 2: City; LastName: State: NEW YORK FirstName: Zip Code: Add ress Address 2: City: State: NEW YORK Zip Code: FILED: BRONX COUNTY CLERK 04/04/2018 03:36 PM INDEX NO. 25060/2015E NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 04/04/2018 Officeofthe New YorkCity Comptroller 1 CentreStreet .~~~;,1~~«'r".