Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022
EXHIBIT H
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
L&T 07/05/2022
03:1108:54
PM INDEX
AM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022
07/05/2022
Workers'
STATE CompenSation . . . .
Board Discharge or Discrimmation Comphant
Mail completed form to: Discrimination Unit " Riverview Center - 150 " Menands, NY 12204
Broadway
TYPE OF BENEFIT CLAIM
¡ Disability BenefitS (Off-the-Job Disability) Social Security #: 6014
Workers'
Compensation (On-the-Job Injury) WCB Case # (For On-the-Job Injury): G310 1442
PLEASE PRINT OR TYPE. ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY PROCESSING OF YOUR COMPLAINT
ANSWER QUESTIONS 6 AND 7 IN DETAIL - ATTACH ADDITIONAL SHEETS IF NECESSARY
SUBMIT IN DUPLICATE TO THE ADDRESS AT THE TOP OF THIS FORM.
1. Employee Name: Kalween Rodriguez
2. Employee Address: 233 Jamaica Avenue #1B, Brooklyn, NY 11207
3. Employer Name: Tov Management
4. Employer Address: P.O.Box 445, Monsey, NY 10952
5. Were you discharged: Yes ¡ No If "Yes", give date: 10/12/2021
6. State in detail the basis for your complaint, the reason you were dismissed and the name of your supervisor or manager or person
who actually dismissed you:
Monty Neiman and David (last name unknown) were the managers who fired me. In February or March of 2021, I told them that
workers'
I needed surgery for my compensation injury, and I have told them this repeatedly since then. They consistently
workers'
threatened me that if I tried to get the surgery through comp they would fire me. They fired me the day of my first comp
7. State the name(s) of others involved. Attach a copy of your dismissal notice, if any, or other documents received: please see
attached termination letter and notice to tenants
8. Where did you work (Indicate address, if different than item 4 above): 233 Jamaica Avenue #1B, Brooklyn, NY 11207
9. Occupation: Building superintendent
Representation"
10. Name and address of your attorney or representative, if any (see statement "On on reverse): Schotter, Millican,
Sinaniyeva & Masilela. LLP, 300 Cadman Plaza West, 12th Floor, Brooklyn, NY 11201
11. Date of accident or first day of disability: 09/20/2019
I AFFIRM UND R PE LTY OF PERJURY THAT THE INFORMATION PROVIDED HEREIN IS TRUE:
10/23/2021 (646) 525-5605
E loyee's Signature Date Telephone Number
WORKER OMP N
OARD
DC-120 (7-17) SEE REVERSE FOR APPLICABLE LAW
DISCR
UNIT
MENANDS,NY
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
L&T 07/05/2022
03:1108:54
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AM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022
07/05/2022
STATE OF NE YORK - WORKERS' COMPENSAT A BOARD
CHECK NOTICE OF RETAINER AND APPEARANCE ¡ NOTICE OF RETAINER AND APPEARANCE - APPELLATE ATTORNEY
ONE
¡ NOTICE OF SUBSTITUTION AND APPEARANCE (Forsubstitutions,ItemC MUSTalsobe completed.)
Social Security No· PaidFamilyLeave("PFL")StartDate,or PFLDiscrimination
pda nÓaent,
WCB Case No.
DC 014 014
Name Address
233 Jamaica Avenue #1B
CLAIMANT Kalween Rodriguez
Brooklyn, NY 11207
EMPLOYER* P.O.Box 445
Tov Management
Monsey, NY 10952
CARRIER
ATTORNEY OR 300 Cadman Plaza West, 12th Floor
Schoh, Mcan, EnanÈeva & Maska, I-1-P
REPRESENTATIVE Brooklyn, NY 11201
Re Presentative's ID No Telephone No. of Atty/Rep. alfclaimis madeundertheVolunteerFirefighters'BenefitLawor theVolunteer
AmbulanceWorkers'BenefitLaw,showas EMPLOYER the liablepolitical
R-115742 (718) 770-3708 subdivisionandenter"X" Inthe appropriatebox.....................................................
¡ VAWBL
A. CLAIMANT COMPLETE THIS SECTION
CHECK ONE:
Please take notice that I have retained the above-named firm/individual to represent me in all proceedings conceming my claim.
Please take notice that I have retained the above-named firm/individual to represent me in my appeal to the Supreme Court, Appellate Division, Third
Department, or the Court of Appeals.
Please take notice that in place of I have retained the above-named to represent and appear for me
in all proceedings concerning my claim.
Workers' Workers'
My claim is under the O Compensation Law Volunteer Firefighter's Benefit Law O Volunteer Ambulance Benefit Law
O Disability Benefits Law -
O Section 120/241 WCL Discharge or Discrimination Complaint O Paid Family Leave Law
Workers'
I hereby authorize the above-named attomey/representative to request and obtain copies of any necessary medical records connected with the
Compensation Board (WCB) case indicated above. In addition, I consent to the transmittal of all medical reports in this case from my health provider(s) to my
attomey/representative. I understand and agree that a licensed representative may appear on my behalf at the request of my attomey.
Workers'
I have also attached a fully executed Form OC-110A (Claimanis Authorization to Disclose Compensation Records) authorizing the above-named
workers'
attorney/representative to access the following compensation case le(s) maintained by the NYS WCB (list by number):
Claimants Signature (Ink Only - Use Blue Ink If Possible) Date 10/23/2021
B. ATTORNEY/REPRESENTATIVE COMPLETE THIS SECT N
I agree to represent the above-named claimant in compliance with the aforementioned Law and Rules and Regulations promulgated thereunder and hereby
notice my retention in the above case. All notices, decisions and other documents are to be sent to the undersigned unless otherwise indicated below. It is
understood that the only fees to be paid in this case are those fixed by the WC Law Judge, the Board, the Conciliator or designated employee of the Chair.
I am (CHECK ONE):
An Attomey at Law ¡ A Licensed Repr tative with Fee-License No. ¤ A Licensed Representative without Fee--License No.
Signature of Attomey/Representative Date 10/23/2021
ATTORNEY OR REPRESENTATIVE WHO IS TO APPEAR, IF OTHER THAN YOURSELF
Name Address Tel No will
appear in this case. All notices, decisions and other documents should be sent to (him, her or them). Fees, if any should be made payable to:
Name Address Tel. No.
C. FOR SUBSTITUTION ONLY - ATTORNEY/REPRESENTATIVE COMPLETE THIS SECTION
A copy of this notice of substitution was served on the day of ,20 , on
Name of Former Attorney or Representative Address
D. REQUEST AND NOTICE TO HEALTH PROVIDER
Workers'
Pursuant to Section 13(f) of the Compensation Law, please transmit copies of all your medical reports to me as the claimants representative.
Signature of Attorney or Representative appearing for claimant
Please Note: A photocopy of this notice shall be deemed as effective as an original
E. CERTIFICATION OF TRANSMITTAL OF THIS NOTICE TO INSURANCE CARRIER/SELF-INSURED EMPLOYER/EM L R Ó)
I hereby certify that a copy of th ce was transmitted to the insurance carrier, self-insured employer or employer named a ove as required by sA GOARD
instructions below).
10/23/2021 0V J
Signature of Attomey or Representative Date
NOTICE TO ATTORNEY OR REPRESENTATIVE:
T
1. This form may be used by an original, substituted or additional attorney or representative. Check appropriate ,1bym.
2. Send a copy of this form to all of the claimants health providers, if applicable.
workers'
3. A copy of this form must be sent to the compensation insurance carrier, self-insured employer or employer (see section E above).
OC-400 Prescribed Workers'Compensation
Board
(7-19) byChair,
SEE IMPORTANT INFORMATION ON REVERSE OC-400 7-19
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
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LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 STATE OF NEW YORK RECEIVED NYSCEF: 08/10/2022
07/05/2022
WORKERS'
COMPENSATION BOARD
PLACE OF HEARING . PART DATE OF HEARING TIME DC CASE No.
98 02/25/2022 11:45AM XXX-XX-6014
11 L v ngston Street-22nd FI.
Brooklyn, NY 11201
Date of this Notice Complaint Filed Date District Office:
02/03/22 11/01/2021 New York City
Claimant
fªª/*a°,°!°,d 9 *
,,e NOTICE OF HEARING
BrSooklyn, NY 11207 RE: DISCHARGE OR DISCRIMINATION COMPLAINT
TO EMPLOYER AND EMPLOYEE
Employer CAREFULLY FOLLOW INSTRUCTIONS LISTED BELOW:
Too Bo The Employer,Employee or other parties must be present at
Monsey, NY 10952 this PRELIMINARY HEARING,
USA You must be prepared to fumish in fuli detail, the names and
addresses of all WITNESSES on whose testimony you will rely
t prove your case.
Claimant Attorney ou must be prepared to fumish a day and time when your
Schotter, Millican, Sinaniyeva & Masilela, LLP / witnesses can attend a hearing.
Fbdman Plaza West
You should NOT produce WITNESS at this time.
Oh
Brooklyn, NY 11201
USA
THERE WILL BE NO ADJOURNMENT EXCEPT FOR GOOD AND
SUFFICIENT CAUSE
IMPORTANT
1. BRING THIS NOTICE WITH YOU.
2. ALL INQUIRIES AND DOCUMENTS REGARDING THIS
COMPLAINT SHOULD INCLUDE THE DC CASE NUMBER.
3.THE EMPLOYER ALONE AND NOT HIS/HER CARRIER SHALL
BE LIABLE FOR ANY PENALTIES AND PAYMENTS REQUIRED
ATENCION EMPLEADOS Y PATRONOS
WC or DB Reference Case No. Si no sabe Ingles, puede Ilamar a nuestra oficina
de informacion para asistencla.
PURPOSE OF HEARING
Due to Social distancing the Board will be holding hearings by phone on the date and time fisted above. Please call
1-518-549-0500, enter the following meeting number 1619 47 9528 #, and you will be connected. The Judge will be
with you momentarily
WORKERS'
THE COMPENSATIONBOARD EMPLOYSAND SERVES PEOPLE WITH DISABIUTIES WITHOUT
DISCRIMINATIONAND ASSURES HEARINO LOCATIONSACcESSIBLE TO THE DISABLED. CONTACT THE
NEAREST BOARD OFFICE IF YOU HAVE SPECIAL ACCESSIBlUTY NEEDS.
DC-16 (12-09)
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
L&T 07/05/2022
03:1108:54
PM INDEX
AM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022
07/05/2022
WORKERS'
COMPENSATION LAW
Sec. 120. Discrimination against employee who bring proceedings. It shall be unlawful for any employer or his
or her duly authorized agent to discharge or in any other manner discriminate against an employee as to his or
her employment because such employee has claimed or attempted to claim compensation from such employer,
or because he or she testified or is about to testify in a proceeding under this chapter and no other valid reason is
. shown to exist for such action by the employer.
Any complaint alleging such an unlawful discrirninatory practice must be filled within two years of the commission
of such practice. Upon finding that an employer has violated this
section, the board shall make an order that any
employee so discriminated against shall be restored to employment or otherwise restored to the position or
privileges he or she would have had but for the discrimination and shall be compensated by his or her employer
for any loss of compensation arising out of such discrimination together with such fees or allowances for services
rendered by an attorney or licensed representative as fixed by the board. Any employer who violates this section
shall be liable to a penalty of not less than one hundred dollars or more than five hundred dollars,as may be
determined by the board. All such penalties shall be paid into the state treasury, AII penalties, compensation and
fees or allowances shall be paid solely by the employer. The employer alone and not his or her carrier shall be
liable for such penalties and payments. Any provision in an insurance policy undertaking to relieve the employer
from liability for such penalties and payments shall be void.
An employer found to be in violation of this section and the aggrieved employee must report to the board as to the
manner of the employer's compliance
thirty within dyas of receipt of a final
to determination. In case of failure
report on compliance, or failure to comply with an order or penalty of the board within thirty days after the order or
notice of penalty is served, except where timely appication to the board for a modification, recision or review of
such order or penalty has been filed under section twenty-three of this chapter, the chair in any such case or, on
the chair's consent, any party may enforce the order or penalty in a fike manner as an award of compensation. .
Sec. 241. Application of other provisions of chapter. AII the powers and duties conferred or imposed upon the
chair and board by this chapter that are necessary for the administration of this article and not inconsistent are, to
that extent, hereby made applicable to this article; and none of the other provisions of this chapter pertaining to
benefits provided by other articles of this chapter shall be construed to be applicable to this article. The provisions
of section one hundred twenty of this chapter shall be applicable as fully as if set forth in this article, except that
penalties paid into the state treasury pursuant thereto under this article shall be applied toward the expenses of
administering this article.
DC-16 (1-09) Reverse . .
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
L&T 07/05/2022
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AM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 STATE OF NEW YORK RECEIVED NYSCEF: 08/10/2022
07/05/2022
WORKERS'
COMPENSATION BOARD
PLACE OF HEARING PART DATE OF HEARING TIME DC CASE NO.
11 vingston Street-22nd FI.
98 OW242022 100M MWW
Brooklyn, NY 11201
Date of this Notice Complaint Filed Date District Office:
03/07/22 11/01/2021 New York City
Claimant
23 Jar a ca e ue #1B NOTICE OF HEARING
Sooklyn, NY 11207 RE: DISCHARGE OR DISCRIMINATION COMPLAINT
TO EMPLOYERANDEMPLOYEE
Employer CAREFULLY FOLLOW INSTRUCTIONS LISTED BELOW:
29 S 8ncy5lt eet See "PURPOSE OF HEARING".
Brooklyn, NY 11211
USA Employer to attend with counsel.
Claimant Attorney
Schotter, Millican, Sinaniyeva & Masilela, LLP
300 Cadman Plaza West
12th Floor
Brooklyn, NY 11201
USA
THERE WILL BE NO ADJOURNMENT EXCEPT FOR GOOD AND
SUFFICIENT CAUSE
IMPORTANT
1. BRING THIS NOTICE WITH YOU.
2. ALL INQUIRIES AND DOCUMENTS REGARDING THIS
COMPLAINT SHOULD INCLUDE THE DC CASE NUMBER.
3.THE EMPLOYER ALONE AND NOT HIS/HER CARRIER SHALL
BE LIABLE FOR ANY PENALTIES AND PAYMENTS REQUIRED
ATENCION EMPLEADOS Y PATRONOS
WC or DB Reference Case No. Si no sabe ingles, puede Ilamar a nuestra oficIna
de informacion para asistencia.
PURPOSE OF HEARING
Consideration of complaint under Section 120.
Due to social distancing the Board w( be holding hearings by phone on the date and time listed above. Please call
1-518-549-0500, enter the following meeting number 1615 67 3276 #, and you will be connected. The Judge will be
with you momentarily.
WORKERS'
THE COMPENSATIONBOARD EMPLOYSAND SERVESPEOPLE WITH DISABILITIESWITHOUT
DISCRIMINATIONAND ASSURES HEARINGLOCATIONSACCESSfBLE TO THE DISABLED. CONTACT THE
NEAREST BOARD OFFICEIF YOU HAVE SPECIAL ACCESSlBILITY NEEDS.
DC-16 (12-09)
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
L&T 07/05/2022
03:1108:54
PM INDEX
AM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022
07/05/2022
WORKERS'
COMPENSATION LAW
Sec. 120. Discrimination against employee who bring proceedings. It shall be unlawful for any employer or his
or her duly authorized agent to discharge or in any other manner discriminate against an employee as to his or
her employment because such employee has claimed or attempted to claim compensation from such ernployer,
or because he or she testified or is about to testify in a proceeding under this chapter and no other valid reason is
shown to exist for such action by the employer.
Any complaint alleging such an unlawful discriminatory practice must be filled within two years of the commission
of such practice. Upon finding that an employer has violated this section, the board shall make an order that any
employee so discriminated against shall be restored to employment or otherwise restored to the position or
privileges he or she would have had but for the discrimination and shall be compensated by his or her employer
for any loss of compensation arising out of such discrimination together with such fees or allowances for services
rendered by an attorney or licensed representative as fixed by the board. Any employer who violates this section
shall be liable to a penalty of not less than one hundred dollars or more than five hundred dollars,as may be
determined by the board. All such penalties shall be paid into the state treasury. AII penalties, compensation and
fees or allowances shall be paid solely by the employer. The employer alone and not his or her carrier shall be
liable for such penalties and payments. Any provision in an insurance policy undertaking to relieve the employer
from liability for such penalties and payments shall be void.
An employer found to be in violation of this section and the aggrieved employee must report to the board as to the
manner of the employer's compliance within thirty dyas of receipt of a final determination. In case of failure to
report on compliance, or failure to comply with an order or penalty of the board within thirty days after the order or
notice of penalty is served, except where timely appication to the board for a modification, recision or review of
such order or penalty has been filed under section twenty-three of this chapter, the chair in any such case or, on
the chair's consent, any party may enforce the order or penalty in a like manner as an award of compensation.
Sec. 241. Application of other provisions of chapter. All the powers and duties conferred or imposed upon the
chair and board by this chapter that are necessary for the administration of this article and not inconsistent are, to
that extent, hereby made applicable to this article; and none of the other provisions of this chapter pertaining to
benefits provided by other articles of this chapter shall be construed to be applicable to this article. The provisions
of section one hundred twenty of this chapter shall be applicable as fully as if set forth in this article, except that
penalties paid into the state treasury pursuant thereto under this article shall be applied toward the expenses of
administering this article.
DC-16 (1-09) Reverse
FILED: KINGS COUNTY
CIVIL COURT
CLERK-08/10/2022
L&T 07/05/2022
03:1108:54
PM INDEX
AM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF DOC. NO. 17 STATE OF NEW YORK RECEIVED NYSCEF: 08/10/2022
07/05/2022
WORKERS'
COMPENSATION BOARD
DISTRICT OFFICE
New York City
DATE OF HEARING W,C, LAW JUDGE DECISION DULY FILED ON COMPLAINT FILED DATE BY DC CASE NO.
02/25/2022 Richburg 03/07/2022 11/01/2021 TA XXX-XX-6014
Claimant
21"®®"2d
ue #1B NOTICE OF DECISION
Brooklyn, NY 11207
USA
RE: DISCHARGE OR DISCRIMINATION COMPLAINT
PURSUANT TO SECTION 120 OR SECTION 241
Employer
County Agency Inc TO ALL PARTIES OF INTEREST
129 South 8th Street Workers'
Brooklyn, NY 11211 Please take notice that pursuant to section 23 of the Compensation Law and
USA B ard rule 13, any party in interest may appeal this decision to the Board Review
reau by filing its appeal in writing, accompanied by the prescribed cover sheet form
RB-89, together with proof of service upon all other parties in interest, within 30 days
/ after notice of the filing of this decision. A claimant who is not represented by an
Claimant Attorney
attorney or licensed representative is not required to file the cover sheet form but may
Schotter, Millican, Sinaniyeva & Masile ,
file an appeal in any wntten form.
300 Cadman Plaza West
Workers'
Please take notice that pursuant to section 23 of the Compensation Law and
ok n NY 11201
Board rule 13, any party in interest may rebut an appeal by another by filing its rebuttal
USA
with the Board Review Bureau in writing, accompanied by the prescribed rebuttal
cover sheet form RB-89.1, together with proof of service upon afl other parties in
interest, within 30 days after service of the appeal. A claimant who is not represented
by an attorney or licensed representative is not required to file the cover sheet form
but may file rebuttal in any written form.
.._
TOTHEEMPLOYERANDEMPLOYEE
Workers' Compensation Law requires, where discrimination occurs on or after
The
October 25,1987 and the employer is found to be in violation of the Law, that the employer
and aggrieved employee report to the Board the manner of the employer's compliance
Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022 EXHIBIT H FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022 07/05/2022 Workers' STATE CompenSation . . . . Board Discharge or Discrimmation Comphant Mail completed form to: Discrimination Unit " Riverview Center - 150 " Menands, NY 12204 Broadway TYPE OF BENEFIT CLAIM ¡ Disability BenefitS (Off-the-Job Disability) Social Security #: 6014 Workers' Compensation (On-the-Job Injury) WCB Case # (For On-the-Job Injury): G310 1442 PLEASE PRINT OR TYPE. ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY PROCESSING OF YOUR COMPLAINT ANSWER QUESTIONS 6 AND 7 IN DETAIL - ATTACH ADDITIONAL SHEETS IF NECESSARY SUBMIT IN DUPLICATE TO THE ADDRESS AT THE TOP OF THIS FORM. 1. Employee Name: Kalween Rodriguez 2. Employee Address: 233 Jamaica Avenue #1B, Brooklyn, NY 11207 3. Employer Name: Tov Management 4. Employer Address: P.O.Box 445, Monsey, NY 10952 5. Were you discharged: Yes ¡ No If "Yes", give date: 10/12/2021 6. State in detail the basis for your complaint, the reason you were dismissed and the name of your supervisor or manager or person who actually dismissed you: Monty Neiman and David (last name unknown) were the managers who fired me. In February or March of 2021, I told them that workers' I needed surgery for my compensation injury, and I have told them this repeatedly since then. They consistently workers' threatened me that if I tried to get the surgery through comp they would fire me. They fired me the day of my first comp 7. State the name(s) of others involved. Attach a copy of your dismissal notice, if any, or other documents received: please see attached termination letter and notice to tenants 8. Where did you work (Indicate address, if different than item 4 above): 233 Jamaica Avenue #1B, Brooklyn, NY 11207 9. Occupation: Building superintendent Representation" 10. Name and address of your attorney or representative, if any (see statement "On on reverse): Schotter, Millican, Sinaniyeva & Masilela. LLP, 300 Cadman Plaza West, 12th Floor, Brooklyn, NY 11201 11. Date of accident or first day of disability: 09/20/2019 I AFFIRM UND R PE LTY OF PERJURY THAT THE INFORMATION PROVIDED HEREIN IS TRUE: 10/23/2021 (646) 525-5605 E loyee's Signature Date Telephone Number WORKER OMP N OARD DC-120 (7-17) SEE REVERSE FOR APPLICABLE LAW DISCR UNIT MENANDS,NY FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022 07/05/2022 STATE OF NE YORK - WORKERS' COMPENSAT A BOARD CHECK NOTICE OF RETAINER AND APPEARANCE ¡ NOTICE OF RETAINER AND APPEARANCE - APPELLATE ATTORNEY ONE ¡ NOTICE OF SUBSTITUTION AND APPEARANCE (Forsubstitutions,ItemC MUSTalsobe completed.) Social Security No· PaidFamilyLeave("PFL")StartDate,or PFLDiscrimination pda nÓaent, WCB Case No. DC 014 014 Name Address 233 Jamaica Avenue #1B CLAIMANT Kalween Rodriguez Brooklyn, NY 11207 EMPLOYER* P.O.Box 445 Tov Management Monsey, NY 10952 CARRIER ATTORNEY OR 300 Cadman Plaza West, 12th Floor Schoh, Mcan, EnanÈeva & Maska, I-1-P REPRESENTATIVE Brooklyn, NY 11201 Re Presentative's ID No Telephone No. of Atty/Rep. alfclaimis madeundertheVolunteerFirefighters'BenefitLawor theVolunteer AmbulanceWorkers'BenefitLaw,showas EMPLOYER the liablepolitical R-115742 (718) 770-3708 subdivisionandenter"X" Inthe appropriatebox..................................................... ¡ VAWBL A. CLAIMANT COMPLETE THIS SECTION CHECK ONE: Please take notice that I have retained the above-named firm/individual to represent me in all proceedings conceming my claim. Please take notice that I have retained the above-named firm/individual to represent me in my appeal to the Supreme Court, Appellate Division, Third Department, or the Court of Appeals. Please take notice that in place of I have retained the above-named to represent and appear for me in all proceedings concerning my claim. Workers' Workers' My claim is under the O Compensation Law Volunteer Firefighter's Benefit Law O Volunteer Ambulance Benefit Law O Disability Benefits Law - O Section 120/241 WCL Discharge or Discrimination Complaint O Paid Family Leave Law Workers' I hereby authorize the above-named attomey/representative to request and obtain copies of any necessary medical records connected with the Compensation Board (WCB) case indicated above. In addition, I consent to the transmittal of all medical reports in this case from my health provider(s) to my attomey/representative. I understand and agree that a licensed representative may appear on my behalf at the request of my attomey. Workers' I have also attached a fully executed Form OC-110A (Claimanis Authorization to Disclose Compensation Records) authorizing the above-named workers' attorney/representative to access the following compensation case le(s) maintained by the NYS WCB (list by number): Claimants Signature (Ink Only - Use Blue Ink If Possible) Date 10/23/2021 B. ATTORNEY/REPRESENTATIVE COMPLETE THIS SECT N I agree to represent the above-named claimant in compliance with the aforementioned Law and Rules and Regulations promulgated thereunder and hereby notice my retention in the above case. All notices, decisions and other documents are to be sent to the undersigned unless otherwise indicated below. It is understood that the only fees to be paid in this case are those fixed by the WC Law Judge, the Board, the Conciliator or designated employee of the Chair. I am (CHECK ONE): An Attomey at Law ¡ A Licensed Repr tative with Fee-License No. ¤ A Licensed Representative without Fee--License No. Signature of Attomey/Representative Date 10/23/2021 ATTORNEY OR REPRESENTATIVE WHO IS TO APPEAR, IF OTHER THAN YOURSELF Name Address Tel No will appear in this case. All notices, decisions and other documents should be sent to (him, her or them). Fees, if any should be made payable to: Name Address Tel. No. C. FOR SUBSTITUTION ONLY - ATTORNEY/REPRESENTATIVE COMPLETE THIS SECTION A copy of this notice of substitution was served on the day of ,20 , on Name of Former Attorney or Representative Address D. REQUEST AND NOTICE TO HEALTH PROVIDER Workers' Pursuant to Section 13(f) of the Compensation Law, please transmit copies of all your medical reports to me as the claimants representative. Signature of Attorney or Representative appearing for claimant Please Note: A photocopy of this notice shall be deemed as effective as an original E. CERTIFICATION OF TRANSMITTAL OF THIS NOTICE TO INSURANCE CARRIER/SELF-INSURED EMPLOYER/EM L R Ó) I hereby certify that a copy of th ce was transmitted to the insurance carrier, self-insured employer or employer named a ove as required by sA GOARD instructions below). 10/23/2021 0V J Signature of Attomey or Representative Date NOTICE TO ATTORNEY OR REPRESENTATIVE: T 1. This form may be used by an original, substituted or additional attorney or representative. Check appropriate ,1bym. 2. Send a copy of this form to all of the claimants health providers, if applicable. workers' 3. A copy of this form must be sent to the compensation insurance carrier, self-insured employer or employer (see section E above). OC-400 Prescribed Workers'Compensation Board (7-19) byChair, SEE IMPORTANT INFORMATION ON REVERSE OC-400 7-19 FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 STATE OF NEW YORK RECEIVED NYSCEF: 08/10/2022 07/05/2022 WORKERS' COMPENSATION BOARD PLACE OF HEARING . PART DATE OF HEARING TIME DC CASE No. 98 02/25/2022 11:45AM XXX-XX-6014 11 L v ngston Street-22nd FI. Brooklyn, NY 11201 Date of this Notice Complaint Filed Date District Office: 02/03/22 11/01/2021 New York City Claimant fªª/*a°,°!°,d 9 * ,,e NOTICE OF HEARING BrSooklyn, NY 11207 RE: DISCHARGE OR DISCRIMINATION COMPLAINT TO EMPLOYER AND EMPLOYEE Employer CAREFULLY FOLLOW INSTRUCTIONS LISTED BELOW: Too Bo The Employer,Employee or other parties must be present at Monsey, NY 10952 this PRELIMINARY HEARING, USA You must be prepared to fumish in fuli detail, the names and addresses of all WITNESSES on whose testimony you will rely t prove your case. Claimant Attorney ou must be prepared to fumish a day and time when your Schotter, Millican, Sinaniyeva & Masilela, LLP / witnesses can attend a hearing. Fbdman Plaza West You should NOT produce WITNESS at this time. Oh Brooklyn, NY 11201 USA THERE WILL BE NO ADJOURNMENT EXCEPT FOR GOOD AND SUFFICIENT CAUSE IMPORTANT 1. BRING THIS NOTICE WITH YOU. 2. ALL INQUIRIES AND DOCUMENTS REGARDING THIS COMPLAINT SHOULD INCLUDE THE DC CASE NUMBER. 3.THE EMPLOYER ALONE AND NOT HIS/HER CARRIER SHALL BE LIABLE FOR ANY PENALTIES AND PAYMENTS REQUIRED ATENCION EMPLEADOS Y PATRONOS WC or DB Reference Case No. Si no sabe Ingles, puede Ilamar a nuestra oficina de informacion para asistencla. PURPOSE OF HEARING Due to Social distancing the Board will be holding hearings by phone on the date and time fisted above. Please call 1-518-549-0500, enter the following meeting number 1619 47 9528 #, and you will be connected. The Judge will be with you momentarily WORKERS' THE COMPENSATIONBOARD EMPLOYSAND SERVES PEOPLE WITH DISABIUTIES WITHOUT DISCRIMINATIONAND ASSURES HEARINO LOCATIONSACcESSIBLE TO THE DISABLED. CONTACT THE NEAREST BOARD OFFICE IF YOU HAVE SPECIAL ACCESSIBlUTY NEEDS. DC-16 (12-09) FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022 07/05/2022 WORKERS' COMPENSATION LAW Sec. 120. Discrimination against employee who bring proceedings. It shall be unlawful for any employer or his or her duly authorized agent to discharge or in any other manner discriminate against an employee as to his or her employment because such employee has claimed or attempted to claim compensation from such employer, or because he or she testified or is about to testify in a proceeding under this chapter and no other valid reason is . shown to exist for such action by the employer. Any complaint alleging such an unlawful discrirninatory practice must be filled within two years of the commission of such practice. Upon finding that an employer has violated this section, the board shall make an order that any employee so discriminated against shall be restored to employment or otherwise restored to the position or privileges he or she would have had but for the discrimination and shall be compensated by his or her employer for any loss of compensation arising out of such discrimination together with such fees or allowances for services rendered by an attorney or licensed representative as fixed by the board. Any employer who violates this section shall be liable to a penalty of not less than one hundred dollars or more than five hundred dollars,as may be determined by the board. All such penalties shall be paid into the state treasury, AII penalties, compensation and fees or allowances shall be paid solely by the employer. The employer alone and not his or her carrier shall be liable for such penalties and payments. Any provision in an insurance policy undertaking to relieve the employer from liability for such penalties and payments shall be void. An employer found to be in violation of this section and the aggrieved employee must report to the board as to the manner of the employer's compliance thirty within dyas of receipt of a final to determination. In case of failure report on compliance, or failure to comply with an order or penalty of the board within thirty days after the order or notice of penalty is served, except where timely appication to the board for a modification, recision or review of such order or penalty has been filed under section twenty-three of this chapter, the chair in any such case or, on the chair's consent, any party may enforce the order or penalty in a fike manner as an award of compensation. . Sec. 241. Application of other provisions of chapter. AII the powers and duties conferred or imposed upon the chair and board by this chapter that are necessary for the administration of this article and not inconsistent are, to that extent, hereby made applicable to this article; and none of the other provisions of this chapter pertaining to benefits provided by other articles of this chapter shall be construed to be applicable to this article. The provisions of section one hundred twenty of this chapter shall be applicable as fully as if set forth in this article, except that penalties paid into the state treasury pursuant thereto under this article shall be applied toward the expenses of administering this article. DC-16 (1-09) Reverse . . FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 STATE OF NEW YORK RECEIVED NYSCEF: 08/10/2022 07/05/2022 WORKERS' COMPENSATION BOARD PLACE OF HEARING PART DATE OF HEARING TIME DC CASE NO. 11 vingston Street-22nd FI. 98 OW242022 100M MWW Brooklyn, NY 11201 Date of this Notice Complaint Filed Date District Office: 03/07/22 11/01/2021 New York City Claimant 23 Jar a ca e ue #1B NOTICE OF HEARING Sooklyn, NY 11207 RE: DISCHARGE OR DISCRIMINATION COMPLAINT TO EMPLOYERANDEMPLOYEE Employer CAREFULLY FOLLOW INSTRUCTIONS LISTED BELOW: 29 S 8ncy5lt eet See "PURPOSE OF HEARING". Brooklyn, NY 11211 USA Employer to attend with counsel. Claimant Attorney Schotter, Millican, Sinaniyeva & Masilela, LLP 300 Cadman Plaza West 12th Floor Brooklyn, NY 11201 USA THERE WILL BE NO ADJOURNMENT EXCEPT FOR GOOD AND SUFFICIENT CAUSE IMPORTANT 1. BRING THIS NOTICE WITH YOU. 2. ALL INQUIRIES AND DOCUMENTS REGARDING THIS COMPLAINT SHOULD INCLUDE THE DC CASE NUMBER. 3.THE EMPLOYER ALONE AND NOT HIS/HER CARRIER SHALL BE LIABLE FOR ANY PENALTIES AND PAYMENTS REQUIRED ATENCION EMPLEADOS Y PATRONOS WC or DB Reference Case No. Si no sabe ingles, puede Ilamar a nuestra oficIna de informacion para asistencia. PURPOSE OF HEARING Consideration of complaint under Section 120. Due to social distancing the Board w( be holding hearings by phone on the date and time listed above. Please call 1-518-549-0500, enter the following meeting number 1615 67 3276 #, and you will be connected. The Judge will be with you momentarily. WORKERS' THE COMPENSATIONBOARD EMPLOYSAND SERVESPEOPLE WITH DISABILITIESWITHOUT DISCRIMINATIONAND ASSURES HEARINGLOCATIONSACCESSfBLE TO THE DISABLED. CONTACT THE NEAREST BOARD OFFICEIF YOU HAVE SPECIAL ACCESSlBILITY NEEDS. DC-16 (12-09) FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 08/10/2022 07/05/2022 WORKERS' COMPENSATION LAW Sec. 120. Discrimination against employee who bring proceedings. It shall be unlawful for any employer or his or her duly authorized agent to discharge or in any other manner discriminate against an employee as to his or her employment because such employee has claimed or attempted to claim compensation from such ernployer, or because he or she testified or is about to testify in a proceeding under this chapter and no other valid reason is shown to exist for such action by the employer. Any complaint alleging such an unlawful discriminatory practice must be filled within two years of the commission of such practice. Upon finding that an employer has violated this section, the board shall make an order that any employee so discriminated against shall be restored to employment or otherwise restored to the position or privileges he or she would have had but for the discrimination and shall be compensated by his or her employer for any loss of compensation arising out of such discrimination together with such fees or allowances for services rendered by an attorney or licensed representative as fixed by the board. Any employer who violates this section shall be liable to a penalty of not less than one hundred dollars or more than five hundred dollars,as may be determined by the board. All such penalties shall be paid into the state treasury. AII penalties, compensation and fees or allowances shall be paid solely by the employer. The employer alone and not his or her carrier shall be liable for such penalties and payments. Any provision in an insurance policy undertaking to relieve the employer from liability for such penalties and payments shall be void. An employer found to be in violation of this section and the aggrieved employee must report to the board as to the manner of the employer's compliance within thirty dyas of receipt of a final determination. In case of failure to report on compliance, or failure to comply with an order or penalty of the board within thirty days after the order or notice of penalty is served, except where timely appication to the board for a modification, recision or review of such order or penalty has been filed under section twenty-three of this chapter, the chair in any such case or, on the chair's consent, any party may enforce the order or penalty in a like manner as an award of compensation. Sec. 241. Application of other provisions of chapter. All the powers and duties conferred or imposed upon the chair and board by this chapter that are necessary for the administration of this article and not inconsistent are, to that extent, hereby made applicable to this article; and none of the other provisions of this chapter pertaining to benefits provided by other articles of this chapter shall be construed to be applicable to this article. The provisions of section one hundred twenty of this chapter shall be applicable as fully as if set forth in this article, except that penalties paid into the state treasury pursuant thereto under this article shall be applied toward the expenses of administering this article. DC-16 (1-09) Reverse FILED: KINGS COUNTY CIVIL COURT CLERK-08/10/2022 L&T 07/05/2022 03:1108:54 PM INDEX AM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF DOC. NO. 17 STATE OF NEW YORK RECEIVED NYSCEF: 08/10/2022 07/05/2022 WORKERS' COMPENSATION BOARD DISTRICT OFFICE New York City DATE OF HEARING W,C, LAW JUDGE DECISION DULY FILED ON COMPLAINT FILED DATE BY DC CASE NO. 02/25/2022 Richburg 03/07/2022 11/01/2021 TA XXX-XX-6014 Claimant 21"®®"2d ue #1B NOTICE OF DECISION Brooklyn, NY 11207 USA RE: DISCHARGE OR DISCRIMINATION COMPLAINT PURSUANT TO SECTION 120 OR SECTION 241 Employer County Agency Inc TO ALL PARTIES OF INTEREST 129 South 8th Street Workers' Brooklyn, NY 11211 Please take notice that pursuant to section 23 of the Compensation Law and USA B ard rule 13, any party in interest may appeal this decision to the Board Review reau by filing its appeal in writing, accompanied by the prescribed cover sheet form RB-89, together with proof of service upon all other parties in interest, within 30 days / after notice of the filing of this decision. A claimant who is not represented by an Claimant Attorney attorney or licensed representative is not required to file the cover sheet form but may Schotter, Millican, Sinaniyeva & Masile , file an appeal in any wntten form. 300 Cadman Plaza West Workers' Please take notice that pursuant to section 23 of the Compensation Law and ok n NY 11201 Board rule 13, any party in interest may rebut an appeal by another by filing its rebuttal USA with the Board Review Bureau in writing, accompanied by the prescribed rebuttal cover sheet form RB-89.1, together with proof of service upon afl other parties in interest, within 30 days after service of the appeal. A claimant who is not represented by an attorney or licensed representative is not required to file the cover sheet form but may file rebuttal in any written form. .._ TOTHEEMPLOYERANDEMPLOYEE Workers' Compensation Law requires, where discrimination occurs on or after The October 25,1987 and the employer is found to be in violation of the Law, that the employer and aggrieved employee report to the Board the manner of the employer's compliance