Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/10/2022
EXHIBIT H
FILED: KINGS CIVIL
COUNTY COURT
CLERK-08/10/2022
L&T 07/01/2022 03:1104:30 PM INDEX
PM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF
2 Pgs
DOC. NO. 218
15Pgs Transmitted
RECEIVED NYSCEF: 07/01/2022
08/10/2022
Received,
Pasternack Tilker Ziegler
Walsh Stanton & Romano ur
Attorneys At Law
August 23, 2021
WORKERS'
COMPENSATION BOARD
P.O. BOX 5205
BINGHAMTON, NY 13902-5205
W.C.B. # :
Claimant: RODRIGUEZ, KALWEEN
Employer: TOV PROPERTY MANAGEMENT CORP.
Carrier: HARTFORD INSURANCE CO.
Claim #:
D/A: 9/20/2019
Our Case #: 115536-001BKFL
Dear Sir orMadame:
This will serve to inform you thatthis firm has recently been retained torepresent the claimant inthe above
o Workers'
captioned Compensation claim. By copy of thisletter,we are informing the carrierof the same.
We are enclosing, where applicable:
til "Notice of Retainer and Substitution (OC-400);
E a Employee Claim (C-3)[and ifapplicable Limited Release of Health Information (C-3.3)] or
o "Amended Employee Claim [and ifapplicable Limited Release of Health Information (C-3.3)];
(C-3)
"Pre-Hearing conference statement (PH-16.2).
go Pursuant to the provisions of 12NYCRR section 300.37(d)(1) and 300.38(d)(1) and (2):
(i)to the best of my knowledge, information and belief,formed after an inquiry reasonable under the
circumstances, the allegations and other factual matters asserted on the enclosed Employee Claim form
(or enclosed amended Employee Claim form which supersedes allpreviously filed Employee Claim
forms, as appropriate) have evidentiary support or ifspecifically so identified, are likely to have
evidentiary support aftera reasonable opportunity for furtherinvestigation or discovery.
(ii) upon information and belief (the source of which information and belief being my client's
representations to me), the following documents that may be used to support the claim are in the
claimant's possession, custody or control,when available: medical reports from treating doctors.
Thank you foryour kind cooperation.
Very trulyyours,
PASTERNACK TILKER ZIEGLER
WALSH STANTON & ROMANO LLP
S#pe 7t. R=
EDGAR N. ROMANO
ENR:kj2
offices locatedin:
MANHArrAN| BROOKLYN| BRONXj QUEENS| NASSAU | SUFFOLK
| WESTCliESTER
| ROCKLAND| ORANGE
Mailing Address:111 Uvingston Street, Ground Floor, Brooklyn, NY 11201 |
800.69237171WWW.workerslaw.com
FILED: KINGS CIVIL
COUNTY COURT
CLERK-08/10/2022
L&T 07/01/2022 03:1104:30 PM INDEX
PM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF
8 Pgs
DOC. NO. 318
15
Pgs Transmitted
RECEIVED NYSCEF: 07/01/2022
08/10/2022
Received,
Employee Claim C-3
State ofNew York - Workers'Compensation Board
for workers'compensationbenefits
Fill out this form toapply because of a work injury
or work-related illness. Type or printneatly.
This brmmay also be filled.out on-line at www.wcb.ny.gov.
WCB Case Number (ifyou know it):
A. YOUR INFORMATION (Employee)
a 8"® 0/3 98
1. Name: ______ Mr----------- 2. Date of Birth:
3. Mailing address: 233 JamaicaAvae Apt m Brooklyn NY 11207
Number
andStreel/PO
Bor/ApartmentNo. City Slate ZipCedo
4. Social Security
Number 6014 5. PhoneNumber (646) 525-5605 6. Gender: Male OFemale
Will you need a translator
if you have to attend
a Board hearing? ¤Yes 2 No If yes, for what language?
_______________
B. YOUR EMPLOYER(S)
1. Employerwhen injured: TOV Management 2. PhoneNumber:
3. Your work address:P.O.Box 445 Monsey NY 10952
Number
andStreet CIly State Z$Code
4. Date you were
hired: Your supervisor's
name: Brane Altman
Q] ___
of any other employer(s)
5. List names/addresses at the time of yourinjurylillness::
DO
7. Did youlose timefrom work at theother employment(s) at thetimeof your injurylillness? Yes No
C. YOUR JOB on the date of the injuryor illness
1 What was your job title or description?
Building Superintendent
2 What types of activities
did you normally
performat work? 6Ú d A WMems . QMyto
renovan on UM t·y
repch m.
3 Was your job? (check
one) Full Time U P ri Time ¡ Seasonal O Volunteer ¡ Other:
4 What was your grosspay (before
taxes)per pay period? CD _ 10. How often were you paid?
412E1(2g
6. Did you receive
lodgingor tips
in addhion
to your pay?¡ Yes
) No If yes, describe:
D. YOUR INJURY OR ILLNESS
9/20/2019
1. Date of injury or date of onset
of illness: 2. Time of Injury:
_____________ AM PM
3..Where didthe happen?
injurylillness (e.g.,1 Main Street, at the front door)
Pottersville,
4. Was this your usual work jocation?
Ýes ¡No If no, why were you at this locatior
5. What were you doing when
you wereinjured or became
ill? (e.g., unloading
a truck,
typing a report)
6. How did the injury/illness
happen? over a pipe andfell on the floor)
(e.g., I tripped
While walking intoa garage doing my rounds, a concreteceilingfellon agr... injuring
my Head.
list body parts affected
7. Explain fully the nature of your injurylillness; left ankle and cut to foreh
( e. g., twisted ad
H.ead
C-3.0 (4-19)Page 1 of2 THEWORKERS'COMPENSATION
BOARDEMPLOYSANDSERVESPEoPLE igggggg
WifHDISABUTES
WITHOUT
DISCRIMINATl0N c- A n +w
FILED: KINGS CIVIL
COUNTY COURT
CLERK-08/10/2022
L&T 07/01/2022 03:1104:30 PM INDEX
PM NO.INDEX
LT-300961-22/KI
NO. 506931/2022
[HO]
NYSCEF
8 Pgs
DOC. NO. 318
15Pgs Transmitted
RECEIVED NYSCEF: 07/01/2022
08/10/2022
Received,
YOUR NAME: Kalween Rodriguez DATE OF INJURY/ILLNESS: 9/20/2019
Rrst MI Last
D. YOUR INJURY OR ILLNESS continued
8. Was an object
(e.g., forklift,
hammer, acid)involvedin the injury/illness?Yes O No If yes, what?
C.Dy10 etIS CR Cs
9. Was the injury the result of the use or operation
of a licensed
motor vehicle? Yes No
If yes, ¤ your vehicle ¡ employer'svehicle ¡other vehicle ¤ Licenseplate number(if known):
If your vehicle
was involved,
give name and addressof yourmotor vehicle
insurancecarrier:
10. Have you given your employer
(or supervisor)
notice of injury/illness?Yes ¡ No
If yes, notice was given to: brifi ]&]Q_Q orally in writingDate notice given: / 24 '2.0
11. Did anyone
see your injury happen? Yes O No Unknown If yes, list names:
E. RETURN TO WORK
1. Did you stop work because
of our injury/illness?
[Z_| Yes, on what date? /20 / 2AICI No, skip to Section
F.
2. Have you returnedto work? Yes O No If yes, on what date? _CC_/_23_<
2 Ol@ U regular
duty O limitedduty
3. If you have retumed
to work,
who are you workingfor now? Same employer ¡ New employer OSelf employed
4. What is your gross
pay (before
taxes)per pay period? How often are you paid?
to
F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
* 1. 09
What was the date of your first treatment?1200019 O None received(skip to question
F-5)
2. Were you treated
on site? Yes ¤ No
3. Where did you receive your first off site medical
treatrnent
for your injury/illness?
Onone received Emergency Room
¤ Doctor's
Office U Clinic/Hospital/Urgent
Care ¡ HospitalStay over 24 hours
o
Name and address where MO
you were first treated: 12Odit l
'281 P hovt AleM VorIC”IN I000 3 Phone Nuinber: Q_-_28_'lD
4. Are you still being treated
for this injurylillness?Yes O No
E
Give the name and address
of the doctor(s) you for this injury/illness:
treating
Phone Number:
@ 5. Do you remember havinganother inju to the same
body part or a similar illness?Yes No
00 ¡No
by a doctor?
If yes, were you treated _ Yes If yes, provide
the nameand addresses of the doctor(s)
who treated
you and COMPLETE AND FILEFORM C-3.3 TOGETHER WITH THIS FORM:
8 6. Was the previousinjury/illness
work related?O Yes O No
for the same
If yes, were you working employer ¡
that you work for now? Yes ¡ No
Workers'
I am hereby makirig a elaim for benefits under the
Compensation Law. My signature
affirms
that the information
I am providing
is true and
accurate to the best of my knowledge
and belief
and with INTENT TO DEFRAUD presents,
Any person who knowingly causes to be presented,
or prepares with knowledge or belief that it will be
presented to, or by an insurer,
or self-insurer,
any information any FALSE MATERIAL STATEMENT or conceals
containing any material fact,
SHALL BE GUILTY OF A CRIME and subject to substantial
FINES AND IMPRISONMENT
Namef alween Rodriguez 08/16/2021
Employee's Signature: _____ ______________Print Date
On behalf of Employee: Print Name: Date:
An indMdual may sign on behalfof the employeeonly If he or she Is legally authorizedto do so and the employeeIs a minor, mentally Incompetentor incapacitated.
..........................................................................................................................................................................................
Icertify to the best of my knowledge, information and belief, formed after minquiry reasonable underthe circumstances, that the allegations and other factual matters
asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery.
_a
Signature of Attorney/Representative (if any): Date:08/16/2021
e ggP___
Print Name:Ri)GAR N. ROMANO MANAGING PARTNER
Title:
ID No., if any:
R 239005 lfLicensed Representative, Ucense No.: Expiration Date:
C-3.0 (4-19) Page 2 of 2
Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/10/2022 EXHIBIT H FILED: KINGS CIVIL COUNTY COURT CLERK-08/10/2022 L&T 07/01/2022 03:1104:30 PM INDEX PM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF 2 Pgs DOC. NO. 218 15Pgs Transmitted RECEIVED NYSCEF: 07/01/2022 08/10/2022 Received, Pasternack Tilker Ziegler Walsh Stanton & Romano ur Attorneys At Law August 23, 2021 WORKERS' COMPENSATION BOARD P.O. BOX 5205 BINGHAMTON, NY 13902-5205 W.C.B. # : Claimant: RODRIGUEZ, KALWEEN Employer: TOV PROPERTY MANAGEMENT CORP. Carrier: HARTFORD INSURANCE CO. Claim #: D/A: 9/20/2019 Our Case #: 115536-001BKFL Dear Sir orMadame: This will serve to inform you thatthis firm has recently been retained torepresent the claimant inthe above o Workers' captioned Compensation claim. By copy of thisletter,we are informing the carrierof the same. We are enclosing, where applicable: til "Notice of Retainer and Substitution (OC-400); E a Employee Claim (C-3)[and ifapplicable Limited Release of Health Information (C-3.3)] or o "Amended Employee Claim [and ifapplicable Limited Release of Health Information (C-3.3)]; (C-3) "Pre-Hearing conference statement (PH-16.2). go Pursuant to the provisions of 12NYCRR section 300.37(d)(1) and 300.38(d)(1) and (2): (i)to the best of my knowledge, information and belief,formed after an inquiry reasonable under the circumstances, the allegations and other factual matters asserted on the enclosed Employee Claim form (or enclosed amended Employee Claim form which supersedes allpreviously filed Employee Claim forms, as appropriate) have evidentiary support or ifspecifically so identified, are likely to have evidentiary support aftera reasonable opportunity for furtherinvestigation or discovery. (ii) upon information and belief (the source of which information and belief being my client's representations to me), the following documents that may be used to support the claim are in the claimant's possession, custody or control,when available: medical reports from treating doctors. Thank you foryour kind cooperation. Very trulyyours, PASTERNACK TILKER ZIEGLER WALSH STANTON & ROMANO LLP S#pe 7t. R= EDGAR N. ROMANO ENR:kj2 offices locatedin: MANHArrAN| BROOKLYN| BRONXj QUEENS| NASSAU | SUFFOLK | WESTCliESTER | ROCKLAND| ORANGE Mailing Address:111 Uvingston Street, Ground Floor, Brooklyn, NY 11201 | 800.69237171WWW.workerslaw.com FILED: KINGS CIVIL COUNTY COURT CLERK-08/10/2022 L&T 07/01/2022 03:1104:30 PM INDEX PM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF 8 Pgs DOC. NO. 318 15 Pgs Transmitted RECEIVED NYSCEF: 07/01/2022 08/10/2022 Received, Employee Claim C-3 State ofNew York - Workers'Compensation Board for workers'compensationbenefits Fill out this form toapply because of a work injury or work-related illness. Type or printneatly. This brmmay also be filled.out on-line at www.wcb.ny.gov. WCB Case Number (ifyou know it): A. YOUR INFORMATION (Employee) a 8"® 0/3 98 1. Name: ______ Mr----------- 2. Date of Birth: 3. Mailing address: 233 JamaicaAvae Apt m Brooklyn NY 11207 Number andStreel/PO Bor/ApartmentNo. City Slate ZipCedo 4. Social Security Number 6014 5. PhoneNumber (646) 525-5605 6. Gender: Male OFemale Will you need a translator if you have to attend a Board hearing? ¤Yes 2 No If yes, for what language? _______________ B. YOUR EMPLOYER(S) 1. Employerwhen injured: TOV Management 2. PhoneNumber: 3. Your work address:P.O.Box 445 Monsey NY 10952 Number andStreet CIly State Z$Code 4. Date you were hired: Your supervisor's name: Brane Altman Q] ___ of any other employer(s) 5. List names/addresses at the time of yourinjurylillness:: DO 7. Did youlose timefrom work at theother employment(s) at thetimeof your injurylillness? Yes No C. YOUR JOB on the date of the injuryor illness 1 What was your job title or description? Building Superintendent 2 What types of activities did you normally performat work? 6Ú d A WMems . QMyto renovan on UM t·y repch m. 3 Was your job? (check one) Full Time U P ri Time ¡ Seasonal O Volunteer ¡ Other: 4 What was your grosspay (before taxes)per pay period? CD _ 10. How often were you paid? 412E1(2g 6. Did you receive lodgingor tips in addhion to your pay?¡ Yes ) No If yes, describe: D. YOUR INJURY OR ILLNESS 9/20/2019 1. Date of injury or date of onset of illness: 2. Time of Injury: _____________ AM PM 3..Where didthe happen? injurylillness (e.g.,1 Main Street, at the front door) Pottersville, 4. Was this your usual work jocation? Ýes ¡No If no, why were you at this locatior 5. What were you doing when you wereinjured or became ill? (e.g., unloading a truck, typing a report) 6. How did the injury/illness happen? over a pipe andfell on the floor) (e.g., I tripped While walking intoa garage doing my rounds, a concreteceilingfellon agr... injuring my Head. list body parts affected 7. Explain fully the nature of your injurylillness; left ankle and cut to foreh ( e. g., twisted ad H.ead C-3.0 (4-19)Page 1 of2 THEWORKERS'COMPENSATION BOARDEMPLOYSANDSERVESPEoPLE igggggg WifHDISABUTES WITHOUT DISCRIMINATl0N c- A n +w FILED: KINGS CIVIL COUNTY COURT CLERK-08/10/2022 L&T 07/01/2022 03:1104:30 PM INDEX PM NO.INDEX LT-300961-22/KI NO. 506931/2022 [HO] NYSCEF 8 Pgs DOC. NO. 318 15Pgs Transmitted RECEIVED NYSCEF: 07/01/2022 08/10/2022 Received, YOUR NAME: Kalween Rodriguez DATE OF INJURY/ILLNESS: 9/20/2019 Rrst MI Last D. YOUR INJURY OR ILLNESS continued 8. Was an object (e.g., forklift, hammer, acid)involvedin the injury/illness?Yes O No If yes, what? C.Dy10 etIS CR Cs 9. Was the injury the result of the use or operation of a licensed motor vehicle? Yes No If yes, ¤ your vehicle ¡ employer'svehicle ¡other vehicle ¤ Licenseplate number(if known): If your vehicle was involved, give name and addressof yourmotor vehicle insurancecarrier: 10. Have you given your employer (or supervisor) notice of injury/illness?Yes ¡ No If yes, notice was given to: brifi ]&]Q_Q orally in writingDate notice given: / 24 '2.0 11. Did anyone see your injury happen? Yes O No Unknown If yes, list names: E. RETURN TO WORK 1. Did you stop work because of our injury/illness? [Z_| Yes, on what date? /20 / 2AICI No, skip to Section F. 2. Have you returnedto work? Yes O No If yes, on what date? _CC_/_23_< 2 Ol@ U regular duty O limitedduty 3. If you have retumed to work, who are you workingfor now? Same employer ¡ New employer OSelf employed 4. What is your gross pay (before taxes)per pay period? How often are you paid? to F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS * 1. 09 What was the date of your first treatment?1200019 O None received(skip to question F-5) 2. Were you treated on site? Yes ¤ No 3. Where did you receive your first off site medical treatrnent for your injury/illness? Onone received Emergency Room ¤ Doctor's Office U Clinic/Hospital/Urgent Care ¡ HospitalStay over 24 hours o Name and address where MO you were first treated: 12Odit l '281 P hovt AleM VorIC”IN I000 3 Phone Nuinber: Q_-_28_'lD 4. Are you still being treated for this injurylillness?Yes O No E Give the name and address of the doctor(s) you for this injury/illness: treating Phone Number: @ 5. Do you remember havinganother inju to the same body part or a similar illness?Yes No 00 ¡No by a doctor? If yes, were you treated _ Yes If yes, provide the nameand addresses of the doctor(s) who treated you and COMPLETE AND FILEFORM C-3.3 TOGETHER WITH THIS FORM: 8 6. Was the previousinjury/illness work related?O Yes O No for the same If yes, were you working employer ¡ that you work for now? Yes ¡ No Workers' I am hereby makirig a elaim for benefits under the Compensation Law. My signature affirms that the information I am providing is true and accurate to the best of my knowledge and belief and with INTENT TO DEFRAUD presents, Any person who knowingly causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information any FALSE MATERIAL STATEMENT or conceals containing any material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT Namef alween Rodriguez 08/16/2021 Employee's Signature: _____ ______________Print Date On behalf of Employee: Print Name: Date: An indMdual may sign on behalfof the employeeonly If he or she Is legally authorizedto do so and the employeeIs a minor, mentally Incompetentor incapacitated. .......................................................................................................................................................................................... Icertify to the best of my knowledge, information and belief, formed after minquiry reasonable underthe circumstances, that the allegations and other factual matters asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery. _a Signature of Attorney/Representative (if any): Date:08/16/2021 e ggP___ Print Name:Ri)GAR N. ROMANO MANAGING PARTNER Title: ID No., if any: R 239005 lfLicensed Representative, Ucense No.: Expiration Date: C-3.0 (4-19) Page 2 of 2