Preview
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021
MV-104 (5/11)PAGE 1 of 2 FOLD HERE
New York StateDepartrnentofMotor Vehicles
Use only for accidents
that)
happert In New York REpoRT OF MOTOR VEHICLE ACCIDENT
Statey www.drnv.ny.gov
- 1
DONOTFORGET
ACCIDENTDATE Page of - DRIVER OF VEHICLE
R(/_SS,H 1 - LICENSESUSPENDED FOR FAILURE TO REPORT
AccidentDate DayofWeek Time Number
of Number Number If 'Yes",Nameof PoliceAgencyorPrecinct
Didpoliceinvestigate &AccidentNumber
Month | Day Year AM Vehicles Injured Killed atscene?
accident
3 / 7 12018 Wednesday 09 : 3 0 O
PM 2 3 W Yes No
__ DRIVEROFVEHICLE 1 VEHICLE2 O etuttiI KIAN O BICYCLIST O OTHERPEDESTRIAN
DriverLicenseIDNumber StateofLicense DriverUcense10Number taleofLicensel2
0 M26464016112602
DriverName-exactly
asprintedonficense(Last.First,M.I) asprintedonlicense(Last,First,M I )
Name-exactly
|MERAN-FAMILIA A JESUS
Address(IncludoNumber& Street) Apt.Number Address(includeNumber& Street) Apt,Number
>
315 SOUTH PARK STREET
O CityorTown State ZipCode CityorTown State ZipCode
ELIZABETH NJ 07205
DateofBirth Sex Number
of Public DateofBirth Sex Number
of Public
h Day Year Peoplein Property Month Day Year Peoplein Property
24 196 0 Vehicle 3 Damaged Vehicle O
Damaged 3
asprintedonregistration
Name-exactly DateofBirth Sex asprintedonregistration
Name-exactly DateofBirth Sex
Month Day Year Month | Day| Year
American United transport I I
Address(tncIvdeNumber& Street) Apt,Number Address
(includeNumber& Street) pt.Number
1165 Ogden Ave .
4
CityorTown State ZipCode CityorTown State ZjpCade
Bronx, New York NY 104 52
PlateNumber VehideYear& Make VehicleType Ins.Code PlateNumber
Stateof Reg StateofReg. VehicleYear&Make VehicleType
Ins Code 5
T687182C NY
|2™ ™™m SE 3 89
Estimated
Costof Property
Damage- Vehicle1 Estimated - Vehicle2
CostofPropertyDamage
O $1.001-S1.500 O 51.501-52.500 D Over52.500 O S1,001-S1,500 O $1,50152,500 O Over52.500 6
Ll.1Describedamageto vehicle1
ACCIDENT
DIAGRAM:Circleoneof the9 diagrams 0-8) if it
(numbered LeftTum RearEnd Sideswipe c G-ic PG--age
to vehicle2
(.9 describes
theaccident,
ordrawyourowndiagrambelowinspace#9 (samedirection)
Number
thevehicles.Yourvehicleis# 1 4---
LeftTurn RightAngle
RightTurn
U.I
..I
52 3 4 -» 3 23
ghtTurn HeadOn Sideswipe
(opposjte
direction)
9. 7· 8· 24
Place Where AccidentOccurred in New YorkState:
County O CityO Village
O Town of . PermanentLandmark
O Roadon whichaccidentoccurredUniversity Avenue Bronx New York
(RouteNumberorStreetName)
25
at 01)intersectingstreet between
185th Street and 187th Street
(RouteNumber
or StreetName)
ON QS
or 2) OE OW of .
Feet Miles Nearest
(Milepost, RouteNumber
intersecting orStreetName)
H n a n
outhbound at the University Avenue between 185th and 187th dropping
off a passenger when vehicle number to driving South on University Avenue stop and
his vehicle is slipped hitting my vehicle on the driver side front bumper '
27
10. Safety
8.WhichVeh.9. Position 12. 13. 16.Injury ff Deceased,
Enter
NamesofAllPersonsinvolved Occupied in/onVehicle Equip.Used Age
Sex A B C Describe
Injuries DateofDeath
C
28
e9h°idøP
o)pe WN
4T1BF1FK6GU175552
ha ssuedPocFo VPece 1 Ame r icanCOuntry Insurance co. u er CA229P17 . 29
NameandAddressof PolicyPeriod
PolicyHolder 1165 Ogden Ave - From 03/01/2018 To 02/28/2019
IfVehiclewasOperated
UnderPermit NameandAddress
(ICC.USDOTor NYSDOT).
giveNo. ofPermitHolder
tf Set-Insured.
give andState 30
Certificate
No.
Date PrintNameofDriver Signature
of Driver
(orRepresentanve') (orRepresentative')
03/08/2018 ofVehiclet MERAN-FAMILIA A JESUS ofVehicle1
* A representativemay signfor the driverif the driveris unableto sign
An acciden repo is no -- - an• iled unless
It Is signed,
Injury
becauseof injuryor death.Ifyouare signingas thedriver'srepresentative,
and if not signed
may result
inthe suspension of your
driver'slicense.
checktheboxthatdescribeswhy thedrivercannotsign. Death
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13CERTIFICATE OF LIABILITY INSURANCE RECEIVED NYSCEF: 12/06/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER INSURER AFFORDING COVERAGE
L.A. RIVERSIDE BROKERAGE AMERICAN TRAN§ CE fPANY
One N floors
1645 ST. NICHOLAS AVE
Brooklyn,IWirtMMiM2GL,
NEW YORK, NY 10040 2u 857-82% -it60 tas
INSURED
DIKSON,CARLOS,A
34 HIGHLAND AVE 3B
YONKERS, NY 10705
AUTOMOBTLE LIABILITY POLICY NUMBER POLICY E FFECTIVE DATE POLICY EXPIRATION DATE
SCHEDULED AUTO B705154 03/01/2018 (12:01AM) 03/01/2019 (12:01AM).
COVERAGES LIMITS OF LIABILITY
BODILY INJURY $100,000 EACH PERSON
$300,000 EACH ACCIDENT
PROPERTY DAMAGE $10,000 EACH ACCIDENT
UNINSURED MOTORIST (INCLUDES SUM) $25,000 EACH PERSON
$50,000 EACH ACCIDENT
MANDATORY PERSONAL INJURY PROTECTION $50,000
ADDITIONAL PIP $150,000
AGGREGATE NO-FAULT $200,000
COMPREHENSIVE COLLISION
DESCRIPTION OF REGISTERED OWNED VEHICLE(S)
2017 TOYOTA HIGHLANDER VIN: STD JZRFH1HS468596 Effective: 03/01/2018
CERTIFICATE HOLDER CANCELLATION
NYC TAXI AND LIMOUSINE COMMISSION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
31-00 47 AVE.3FL. 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF T,
LONG ISLAND CITY NY 11101 BUT FAILURE TO DO SO SHALL IMP OSE NO OBLIGATION OR LIABILITY OF ANY
KIND UPON THE INSURER OR REPRESENTATIVES
DISCLAIMER
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),
OR PRODUCER, AND THE CERTIFICATE HOLDER, NOR DOES IT AFFIRMATIVELY OR NEGATIVELY AMEND,.
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED THEREON.
AUTHORIZED REPRESE.NTATIVE
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021
INDIVIDUAL OWNER/DRIVER EXCESS LIABILITY COVERAGE IN MOTOR
VEHICLE ACCIDENTS
TO: MOTOR VEHICLE OPERATOR DATE:
NAME:
ADDRESS:
TEL. #:
DATE OF ACCIDENT: 03/07/2018
POLICY NUMBER: B705154
POLICY LIMITS: 100/300/10
BM3 FILE #: 1022930
VEHICLE PLATE # T723688C
I , being duly sworn deposes and says:
1. Did you own the vehicle that was involved in the accident on 03/07/2018?
Answer: YES or NO
1. At the time accident, did you have any excess or umbrella liability insurance policies in
your name, the name of your spouse, or the name of any relative with whom you reside(d)?
Answer: YES or NO
2. At the time of the accident, did you own another vehicle/private vehicle?
Answer: YES or NO
3. Did any relative residing with you at the time of accident own a vepicle/private vehicle?
Answer: YES or NO
12/31/2018 9:09:02 AM Batch: 28614452
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021
4. If you answered YES to any of the questions in #2 through #4, provide the following
information:
Name of Insurance Company
Policy Number:
Dates of Coverage
Amount of Coverage
Excess or Umbrella Coverage Information
Print name: TLÎOS $ O Signature: +
Sworn to before me this
day of Ñ , 20 f
DOMINGA PIMENTEL
Notary Pubho, State of New Ybik
No.02PI8330615
in New York County
Qualified
Comrmaston ExpiresSept21, 2019
Notary Public
PLEASE COMPLETE ALL FORMS, NOTARIZE AND RETURN ALL ORIGINALS TO
MORRISSEY & PC IN THE SELF-
BAKER, MCEVOY, MOSKOVITS, STAMPED,
ADDRESSED ENVELOPE.
12/31/2018 9:09:02 AM Batch: 28614452
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021
MV-104 (5/11)PAGE 1 of 2 FOLD HERE
New York StateDepartment ofMotor Vehicles
"°,,°"'C"°°‡Tha.t
REPORT OF MOTOR VEHICLE ACCIDENT
www.dmv.ny.gov
BEFORE COMPLETINGTHIS FORM, READ THE INSTRUCTIONStN SECTIONA ON PAGE 2
a co Page 1 of 1 RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT
AccidentDate DayofWeek TIrne Numberof Number Number DidpoliceinvestigateIf "Yes".NameofPoliceAgencyor Precinct&AccidentNumber
Month | Day [ Year AM VeNcles Irgured Killed accident
atscene?
12 : 00
3 | 7 h016 WEDNESDAY pM 2 O 0 O Yes K No
DRIVEROF VEHiCLE 1 VEHICLE2 O PEDESTRIAN O BICYCLIST O OTHER PEDESTRIAN
DriverLicenseIDNumber Stateof License DriverLicenseIDNumber tateofLicense 2
O 564 566 749 NY
DriverNamnxactly asprintedonlicense(Last.First,M.I.) asprintedonlicense(Last.First,M.I.)
Name-exactly
DIKSON CARLOS
Address(includeNurnber
& Street) Apt.Number Address(includeNumber& Street) Apt.Number
fr 34 HIGHLAND AVE 3B
Q CityorTown State ZipCode Cityor Town State ZipCode
YONKERS NY 10705
Dateof Birth Sex Numberof Public Dateof Birth Sex Numberof Public
Mo
Day23 1961 M c Da d ce Dr ed 3
asprintedonregistration
Name-exactly Dateof Birth Sex NamMXectlyasprintedonregistration Dateof Birth Sex
Month Day Year Month Day Year
DTKSON CARLOS
Address(IndudeNumber& Streen Apt.Number AddressUndudeNumber& Street) Apt.Number
34 HIGHLAND AVE 3B 4
CityorTown State ZipCode CityorTown State ZipCode
YONKERS NY 10705
PlateNumber StateofReg.VehicleYear& Make VehicleType Ins.CÃ
PlateNumber Stateat Reg. VehicleYear& Make VehicleType
tas.Code 5
T723688C NY 2017 TOYOT SUBN 036 T687182C NY TOYOTA
Estimated - VeNcle1
Costof PropertyDarnage Estimated - Vehicle2
Costof PropertyOamage
D 51.001-$1,500 D $L$01-52,500 O Over52,500 D $1,001-$L500 O $1,501-s2,500 O over52,500 6
W DescrIbedamageto vehicle1
ACCIDENTDIAGRAM:Circleoneof the9 diagrams(numbered
0-8) If It
LeftTum RearEnd Sideswipe Describedamageto vehFcle
2
(9 theaccident,ordrawyourowndiagrambelowInspace#9. (samedirection)
*(
describes
Numberthevehicles.Yourvehicleis# 1 + +
LeftTum I ightAngle
RightTum
RightTurn HeadOn SIdeswipe
d rection)
fopposite
9. 6. 7. s. 24
PlaceWhere AccidentOccurred in New YorkState:
County O CityO VillageO Town of BRONX . PermanentLandrnark
O Roadonwhich accidentoccurred UNIVERSITY AVE
I- (RouteNumberor StreetName)
at 01)intersecting street WEST
180 STREET 25
(RouteNumberorStreetName)
ON OS
a 2) DE OW of
Feet Mies Nearestintersecting
(Milepost. RouteNumber
or StreetNama)
26
Howdid theaccidenthappen?
I WAS ENTERING IN A PARKING POSITION, IT WAS SNOWING AND SLIPPERY WHEN MY VEHICLE
So
o SIDESWIPED VEHICLE 2 . DAMAGES TO FRONT RIGHT TIRE . ATT DIKSON CARLOS 846-836 -3680
27
B.WhichVeh.9. Position
10, Safety12. 13. 16.Injury If Deceased.
Enter
NamesofAllPersorisInvolved Occupied in/onVehicle Equip.Used Age
Sex A B DescribeInjuries Dateof Death
DIKSON CARLOS 1 1 M
28
*(L
Sn*v*,9hi
le ) 5TDJZRFH1HS46 8596
ha s I F h e 1 AMERICAN TRANSIT INSURANCE PNu erB705154
29
NameandAddressof PolicyPeriod
Holder
Policy rrom 3/1/ 2018 in 3 /1/2019
IfVehiclewasOperated
UnderPermit NameandAddress
0 (ICC.USDOTor NYSDOT),
giveNo. ofPermitHokler
If Self-insured,
give 30
No.
Certificate
Date PrintNameofDriver ofDriver
Signature
(orRepresentative*) (orRepresentative7
4 / 4 /2018 ofvehiclet DIKSON CARLOS ofvehicle1
* A representativernay signfor the driverif the driveris unableto sign
Injury
becauseof Injuryor death.Ifyou are signingas the driver'srepresentative,
checkthe boxthatdescribeswhythe drivercannotsign. Ibath .
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021
AFFIDAVIT
DATE OF ACCIDENT: 03/07/2018
POLICY NUMBER: B705154
POLICY LIMITS: 100/300/10
BM3 FILE #: 1022930
VEHICLE PLATE # T723688C
I, 53V7 , to the best of my knowledge and belief, state the
following answers to be true and correct:
1. At the time of the accident, were you an employee (W-2) or independent contractor
(1099/for hire)?
(a) Employee (W-2)
Independent Contractor (1099
Please circle (a) or (b).
Ifyou circled (a) Employee (W-2), please provide employer's name, address and telephone
number:
1. Was the vehicle being operated pursuant to a lease at the time of the accident?
YES [ ] NO [
If YES, please provide a copy of the lease agreement.
2. Are you in possession of any maintenance, inspection, or repair records for the vehicle
involved in the accident?
YES [ ] NO [
If YES, please provide all maintenance and repair records for one year prior to the
accident in question.
12/31/2018 9:09:02 AM Batch: 28614452
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021
3. Are you in possession of any photos, videos, or repair estimates for the vehicle involved in
the accident?
YES [ ] NO [ ]
IfYES, please provide copies of all photos, videos and/or repair estimates.
4. Are you in possession of any Trip sheets or GPS records for the vehicle involved in the
accident?
YES [ ] NO [
IfYES, please provide copies of all Trip sheets and/or GPS records.
IF YOU HAVE ANSWERED THAT YOU ARE IN POSSESSION OF ANY RECORDS OR
DOCUMENTS, PLEASE REMEMBER TO ATTACH ANY/ALL DOCUMENTS IN YOUR
POSSESSION AND MAIL THEM BACK TO THIS OFFICE PROMPTLY.
KINDLY SIGN THE AFFIDAVITS AND HAVE THEM NOTARIZED. THEN, RETURN ALL
SIGNED AND NOTARIZED AFFIDAVITS TO BAKER, MCEVOY, MORRISSEY &
MOSKOVITS, P.C., IN THE ENCLOSED SELF-ADDRESSED ENVELOPE.
Signa
Print Name and Title
Sworn to before me on
day od , 20J_ ooMINGA PIMENTEL
of NewM
. Notary Public, State
No. 02P16330615
in New York County
Qualified
Comnnssion Expires Sept21, 2019
Notary Publi
12/31/2018 9:09:02 AM Batch: 28614452
Preview
FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021 MV-104 (5/11)PAGE 1 of 2 FOLD HERE New York StateDepartrnentofMotor Vehicles Use only for accidents that) happert In New York REpoRT OF MOTOR VEHICLE ACCIDENT Statey www.drnv.ny.gov - 1 DONOTFORGET ACCIDENTDATE Page of - DRIVER OF VEHICLE R(/_SS,H 1 - LICENSESUSPENDED FOR FAILURE TO REPORT AccidentDate DayofWeek Time Number of Number Number If 'Yes",Nameof PoliceAgencyorPrecinct Didpoliceinvestigate &AccidentNumber Month | Day Year AM Vehicles Injured Killed atscene? accident 3 / 7 12018 Wednesday 09 : 3 0 O PM 2 3 W Yes No __ DRIVEROFVEHICLE 1 VEHICLE2 O etuttiI KIAN O BICYCLIST O OTHERPEDESTRIAN DriverLicenseIDNumber StateofLicense DriverUcense10Number taleofLicensel2 0 M26464016112602 DriverName-exactly asprintedonficense(Last.First,M.I) asprintedonlicense(Last,First,M I ) Name-exactly |MERAN-FAMILIA A JESUS Address(IncludoNumber& Street) Apt.Number Address(includeNumber& Street) Apt,Number > 315 SOUTH PARK STREET O CityorTown State ZipCode CityorTown State ZipCode ELIZABETH NJ 07205 DateofBirth Sex Number of Public DateofBirth Sex Number of Public h Day Year Peoplein Property Month Day Year Peoplein Property 24 196 0 Vehicle 3 Damaged Vehicle O Damaged 3 asprintedonregistration Name-exactly DateofBirth Sex asprintedonregistration Name-exactly DateofBirth Sex Month Day Year Month | Day| Year American United transport I I Address(tncIvdeNumber& Street) Apt,Number Address (includeNumber& Street) pt.Number 1165 Ogden Ave . 4 CityorTown State ZipCode CityorTown State ZjpCade Bronx, New York NY 104 52 PlateNumber VehideYear& Make VehicleType Ins.Code PlateNumber Stateof Reg StateofReg. VehicleYear&Make VehicleType Ins Code 5 T687182C NY |2™ ™™m SE 3 89 Estimated Costof Property Damage- Vehicle1 Estimated - Vehicle2 CostofPropertyDamage O $1.001-S1.500 O 51.501-52.500 D Over52.500 O S1,001-S1,500 O $1,50152,500 O Over52.500 6 Ll.1Describedamageto vehicle1 ACCIDENT DIAGRAM:Circleoneof the9 diagrams 0-8) if it (numbered LeftTum RearEnd Sideswipe c G-ic PG--age to vehicle2 (.9 describes theaccident, ordrawyourowndiagrambelowinspace#9 (samedirection) Number thevehicles.Yourvehicleis# 1 4--- LeftTurn RightAngle RightTurn U.I ..I 52 3 4 -» 3 23 ghtTurn HeadOn Sideswipe (opposjte direction) 9. 7· 8· 24 Place Where AccidentOccurred in New YorkState: County O CityO Village O Town of . PermanentLandmark O Roadon whichaccidentoccurredUniversity Avenue Bronx New York (RouteNumberorStreetName) 25 at 01)intersectingstreet between 185th Street and 187th Street (RouteNumber or StreetName) ON QS or 2) OE OW of . Feet Miles Nearest (Milepost, RouteNumber intersecting orStreetName) H n a n outhbound at the University Avenue between 185th and 187th dropping off a passenger when vehicle number to driving South on University Avenue stop and his vehicle is slipped hitting my vehicle on the driver side front bumper ' 27 10. Safety 8.WhichVeh.9. Position 12. 13. 16.Injury ff Deceased, Enter NamesofAllPersonsinvolved Occupied in/onVehicle Equip.Used Age Sex A B C Describe Injuries DateofDeath C 28 e9h°idøP o)pe WN 4T1BF1FK6GU175552 ha ssuedPocFo VPece 1 Ame r icanCOuntry Insurance co. u er CA229P17 . 29 NameandAddressof PolicyPeriod PolicyHolder 1165 Ogden Ave - From 03/01/2018 To 02/28/2019 IfVehiclewasOperated UnderPermit NameandAddress (ICC.USDOTor NYSDOT). giveNo. ofPermitHolder tf Set-Insured. give andState 30 Certificate No. Date PrintNameofDriver Signature of Driver (orRepresentanve') (orRepresentative') 03/08/2018 ofVehiclet MERAN-FAMILIA A JESUS ofVehicle1 * A representativemay signfor the driverif the driveris unableto sign An acciden repo is no -- - an• iled unless It Is signed, Injury becauseof injuryor death.Ifyouare signingas thedriver'srepresentative, and if not signed may result inthe suspension of your driver'slicense. checktheboxthatdescribeswhy thedrivercannotsign. Death FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13CERTIFICATE OF LIABILITY INSURANCE RECEIVED NYSCEF: 12/06/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PRODUCER INSURER AFFORDING COVERAGE L.A. RIVERSIDE BROKERAGE AMERICAN TRAN§ CE fPANY One N floors 1645 ST. NICHOLAS AVE Brooklyn,IWirtMMiM2GL, NEW YORK, NY 10040 2u 857-82% -it60 tas INSURED DIKSON,CARLOS,A 34 HIGHLAND AVE 3B YONKERS, NY 10705 AUTOMOBTLE LIABILITY POLICY NUMBER POLICY E FFECTIVE DATE POLICY EXPIRATION DATE SCHEDULED AUTO B705154 03/01/2018 (12:01AM) 03/01/2019 (12:01AM). COVERAGES LIMITS OF LIABILITY BODILY INJURY $100,000 EACH PERSON $300,000 EACH ACCIDENT PROPERTY DAMAGE $10,000 EACH ACCIDENT UNINSURED MOTORIST (INCLUDES SUM) $25,000 EACH PERSON $50,000 EACH ACCIDENT MANDATORY PERSONAL INJURY PROTECTION $50,000 ADDITIONAL PIP $150,000 AGGREGATE NO-FAULT $200,000 COMPREHENSIVE COLLISION DESCRIPTION OF REGISTERED OWNED VEHICLE(S) 2017 TOYOTA HIGHLANDER VIN: STD JZRFH1HS468596 Effective: 03/01/2018 CERTIFICATE HOLDER CANCELLATION NYC TAXI AND LIMOUSINE COMMISSION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 31-00 47 AVE.3FL. 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF T, LONG ISLAND CITY NY 11101 BUT FAILURE TO DO SO SHALL IMP OSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER OR REPRESENTATIVES DISCLAIMER THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), OR PRODUCER, AND THE CERTIFICATE HOLDER, NOR DOES IT AFFIRMATIVELY OR NEGATIVELY AMEND,. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED THEREON. AUTHORIZED REPRESE.NTATIVE FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021 INDIVIDUAL OWNER/DRIVER EXCESS LIABILITY COVERAGE IN MOTOR VEHICLE ACCIDENTS TO: MOTOR VEHICLE OPERATOR DATE: NAME: ADDRESS: TEL. #: DATE OF ACCIDENT: 03/07/2018 POLICY NUMBER: B705154 POLICY LIMITS: 100/300/10 BM3 FILE #: 1022930 VEHICLE PLATE # T723688C I , being duly sworn deposes and says: 1. Did you own the vehicle that was involved in the accident on 03/07/2018? Answer: YES or NO 1. At the time accident, did you have any excess or umbrella liability insurance policies in your name, the name of your spouse, or the name of any relative with whom you reside(d)? Answer: YES or NO 2. At the time of the accident, did you own another vehicle/private vehicle? Answer: YES or NO 3. Did any relative residing with you at the time of accident own a vepicle/private vehicle? Answer: YES or NO 12/31/2018 9:09:02 AM Batch: 28614452 FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021 4. If you answered YES to any of the questions in #2 through #4, provide the following information: Name of Insurance Company Policy Number: Dates of Coverage Amount of Coverage Excess or Umbrella Coverage Information Print name: TLÎOS $ O Signature: + Sworn to before me this day of Ñ , 20 f DOMINGA PIMENTEL Notary Pubho, State of New Ybik No.02PI8330615 in New York County Qualified Comrmaston ExpiresSept21, 2019 Notary Public PLEASE COMPLETE ALL FORMS, NOTARIZE AND RETURN ALL ORIGINALS TO MORRISSEY & PC IN THE SELF- BAKER, MCEVOY, MOSKOVITS, STAMPED, ADDRESSED ENVELOPE. 12/31/2018 9:09:02 AM Batch: 28614452 FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021 MV-104 (5/11)PAGE 1 of 2 FOLD HERE New York StateDepartment ofMotor Vehicles "°,,°"'C"°°‡Tha.t REPORT OF MOTOR VEHICLE ACCIDENT www.dmv.ny.gov BEFORE COMPLETINGTHIS FORM, READ THE INSTRUCTIONStN SECTIONA ON PAGE 2 a co Page 1 of 1 RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT AccidentDate DayofWeek TIrne Numberof Number Number DidpoliceinvestigateIf "Yes".NameofPoliceAgencyor Precinct&AccidentNumber Month | Day [ Year AM VeNcles Irgured Killed accident atscene? 12 : 00 3 | 7 h016 WEDNESDAY pM 2 O 0 O Yes K No DRIVEROF VEHiCLE 1 VEHICLE2 O PEDESTRIAN O BICYCLIST O OTHER PEDESTRIAN DriverLicenseIDNumber Stateof License DriverLicenseIDNumber tateofLicense 2 O 564 566 749 NY DriverNamnxactly asprintedonlicense(Last.First,M.I.) asprintedonlicense(Last.First,M.I.) Name-exactly DIKSON CARLOS Address(includeNurnber & Street) Apt.Number Address(includeNumber& Street) Apt.Number fr 34 HIGHLAND AVE 3B Q CityorTown State ZipCode Cityor Town State ZipCode YONKERS NY 10705 Dateof Birth Sex Numberof Public Dateof Birth Sex Numberof Public Mo Day23 1961 M c Da d ce Dr ed 3 asprintedonregistration Name-exactly Dateof Birth Sex NamMXectlyasprintedonregistration Dateof Birth Sex Month Day Year Month Day Year DTKSON CARLOS Address(IndudeNumber& Streen Apt.Number AddressUndudeNumber& Street) Apt.Number 34 HIGHLAND AVE 3B 4 CityorTown State ZipCode CityorTown State ZipCode YONKERS NY 10705 PlateNumber StateofReg.VehicleYear& Make VehicleType Ins.CÃ PlateNumber Stateat Reg. VehicleYear& Make VehicleType tas.Code 5 T723688C NY 2017 TOYOT SUBN 036 T687182C NY TOYOTA Estimated - VeNcle1 Costof PropertyDarnage Estimated - Vehicle2 Costof PropertyOamage D 51.001-$1,500 D $L$01-52,500 O Over52,500 D $1,001-$L500 O $1,501-s2,500 O over52,500 6 W DescrIbedamageto vehicle1 ACCIDENTDIAGRAM:Circleoneof the9 diagrams(numbered 0-8) If It LeftTum RearEnd Sideswipe Describedamageto vehFcle 2 (9 theaccident,ordrawyourowndiagrambelowInspace#9. (samedirection) *( describes Numberthevehicles.Yourvehicleis# 1 + + LeftTum I ightAngle RightTum RightTurn HeadOn SIdeswipe d rection) fopposite 9. 6. 7. s. 24 PlaceWhere AccidentOccurred in New YorkState: County O CityO VillageO Town of BRONX . PermanentLandrnark O Roadonwhich accidentoccurred UNIVERSITY AVE I- (RouteNumberor StreetName) at 01)intersecting street WEST 180 STREET 25 (RouteNumberorStreetName) ON OS a 2) DE OW of Feet Mies Nearestintersecting (Milepost. RouteNumber or StreetNama) 26 Howdid theaccidenthappen? I WAS ENTERING IN A PARKING POSITION, IT WAS SNOWING AND SLIPPERY WHEN MY VEHICLE So o SIDESWIPED VEHICLE 2 . DAMAGES TO FRONT RIGHT TIRE . ATT DIKSON CARLOS 846-836 -3680 27 B.WhichVeh.9. Position 10, Safety12. 13. 16.Injury If Deceased. Enter NamesofAllPersorisInvolved Occupied in/onVehicle Equip.Used Age Sex A B DescribeInjuries Dateof Death DIKSON CARLOS 1 1 M 28 *(L Sn*v*,9hi le ) 5TDJZRFH1HS46 8596 ha s I F h e 1 AMERICAN TRANSIT INSURANCE PNu erB705154 29 NameandAddressof PolicyPeriod Holder Policy rrom 3/1/ 2018 in 3 /1/2019 IfVehiclewasOperated UnderPermit NameandAddress 0 (ICC.USDOTor NYSDOT), giveNo. ofPermitHokler If Self-insured, give 30 No. Certificate Date PrintNameofDriver ofDriver Signature (orRepresentative*) (orRepresentative7 4 / 4 /2018 ofvehiclet DIKSON CARLOS ofvehicle1 * A representativernay signfor the driverif the driveris unableto sign Injury becauseof Injuryor death.Ifyou are signingas the driver'srepresentative, checkthe boxthatdescribeswhythe drivercannotsign. Ibath . FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021 AFFIDAVIT DATE OF ACCIDENT: 03/07/2018 POLICY NUMBER: B705154 POLICY LIMITS: 100/300/10 BM3 FILE #: 1022930 VEHICLE PLATE # T723688C I, 53V7 , to the best of my knowledge and belief, state the following answers to be true and correct: 1. At the time of the accident, were you an employee (W-2) or independent contractor (1099/for hire)? (a) Employee (W-2) Independent Contractor (1099 Please circle (a) or (b). Ifyou circled (a) Employee (W-2), please provide employer's name, address and telephone number: 1. Was the vehicle being operated pursuant to a lease at the time of the accident? YES [ ] NO [ If YES, please provide a copy of the lease agreement. 2. Are you in possession of any maintenance, inspection, or repair records for the vehicle involved in the accident? YES [ ] NO [ If YES, please provide all maintenance and repair records for one year prior to the accident in question. 12/31/2018 9:09:02 AM Batch: 28614452 FILED: BRONX COUNTY CLERK 12/06/2021 03:17 PM INDEX NO. 35510/2020E NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 12/06/2021 3. Are you in possession of any photos, videos, or repair estimates for the vehicle involved in the accident? YES [ ] NO [ ] IfYES, please provide copies of all photos, videos and/or repair estimates. 4. Are you in possession of any Trip sheets or GPS records for the vehicle involved in the accident? YES [ ] NO [ IfYES, please provide copies of all Trip sheets and/or GPS records. IF YOU HAVE ANSWERED THAT YOU ARE IN POSSESSION OF ANY RECORDS OR DOCUMENTS, PLEASE REMEMBER TO ATTACH ANY/ALL DOCUMENTS IN YOUR POSSESSION AND MAIL THEM BACK TO THIS OFFICE PROMPTLY. KINDLY SIGN THE AFFIDAVITS AND HAVE THEM NOTARIZED. THEN, RETURN ALL SIGNED AND NOTARIZED AFFIDAVITS TO BAKER, MCEVOY, MORRISSEY & MOSKOVITS, P.C., IN THE ENCLOSED SELF-ADDRESSED ENVELOPE. Signa Print Name and Title Sworn to before me on day od , 20J_ ooMINGA PIMENTEL of NewM . Notary Public, State No. 02P16330615 in New York County Qualified Comnnssion Expires Sept21, 2019 Notary Publi 12/31/2018 9:09:02 AM Batch: 28614452