On March 09, 2022 a
Exhibit,Appendix
was filed
involving a dispute between
Kalween Rodriguez,
and
Metropolitan Realty Management, Inc.,
Metropolitan Realty & Management Ny Inc,
Tov Management Corp.,
Tov Property Management Corp.,
for Torts - Other Negligence (Premises)
in the District Court of Kings County.
Preview
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 08/10/2022
EXHIBIT N
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. ° NO.
*'s 23 Workers' RECEIVED NYSCEF: 08/10/2022
State of New York - Compensation Board
°ª4
Employer's First Report of
Work-Related Injury/lliness
A work-related injury or illness must be reported within 10 days (Per Section 110) of the injury/illnessor be subject to a penalty.
Workers'
Employers are not required to submit form C-2F to the Compensation Board if the employer's insurer will be submitting
the accident information electronically tothe Board on the employer's behalf. Ifyou need assistance completing this form, please
contact your insurer for guidance on the best method of reporting work-related accident information. Ifyou submit thisform to
the Board, please send it toP.O. Box 5205, Binghamton, NY 13902 and provide a copy to your insurer.
Employee Name Kalween Rodriquez
WCB Case Number (JCN) Date of Injury 09/20/2019
Claim Administrator Claim Number
INSURER / CLAIM ADMINISTRATOR INFORMATION
Insurer Name Oriska Insurance Carrier Insurer ID
Name
Info/Attn
Address 1310 UticaStreet, POB 855
City Oriskany State NY
Postal Code 13424 Country
Claim Admin ID
EMPLOYEE INFORMATION
First Name Kalween Middle Name/Initial
Last Name Rodriguez Suffix
Mailing Address 233 Jamaica Avenue, #1B
City Brooklyn State NY
Postal Code 11207 Country
Phone Number 5604 Date of Hire 10/01/2016
Date of Birth 1684 Gender Male ¡ Female ¡Unknown
Employee SSN 014
Occupation Description Superintendent
C-2F (1-14) Page of www.wch.ny.gov
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 08/10/2022
CLAIM INFORMATION
Time of Injury unknown Date Employer Had Knowledge of the Injury 9/20/2019
Employment Status fulltime Date Employer Had Knowledge of Date of Disability
Estimated Weekly Wage 700 Number of Days Worked Per Week 5
Work Week Type O Standard Work Week ¡ Fixed Work Week OVaried Work Week
Work Days Scheduled ¡ Sun ¡Mon ¡Tues ¡Wed ¡Thurs ¡Fri ¡ Sat
EMPLOYEE INJURY
Full Wages Paid for Date of Injury ¡Yes ¡No Employer Paid Salary in Lieu of Compensation ¡Yes ¡No
InitialTreatment O No Medical Treatment ¡Minor On-Site Treatment By Employer OMinor Clinic/HospitalTreatment
¡Emergency Evaluation ¡Hospitalization Greater Than 24 Hours OFuture Major Medical/Lost Time Anticipated
Death Result of Injury ¡Yes ¡No OUnknown Date of Death Number of Dependents
Nature of Injury (ie Laceration, Bums, Fracture,Strain,etc) cut
Part of Body (i eleftarm, rightfoot,head, multiple,etc) cheek
Cause of injury (i eMotor Vehicle,Machine, Strainor injuryby lifting,
etc)
Accident/Injury Description (see instructions)
employee was in garage and some debris fell
on him
WORK STATUS
InitialDate Last Day Worked n/a Return To Work Type ¡Actual OReleased
InitialDate Began Physical Restrictions ¡Yes ¡No
Disability
InitialReturn to Work Date 09/20/2021 Return To Work Same Employer ¡Yes ¡No
ACCIDENT LOCATION AND WITNESSES
Premises (see instructions) ¡Employer ¡Lessee ¡Other
Organization Name
Street State
City Postal Code
County Country
Location Narrative garage
Witnesses Business Phone Number
C-2F (1-14) Page of www.wcb.ny.gov
FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 08/10/2022
EMPLOYER INFORMATION
Name County Agency Inc. Employer FEIN 285
UI Number Manual Classification Code
Industry Code
info/Attn
Malling Address 129 S 8 Street
City Brooklyn State NY
Postal Code 11211 Country
Physical Addr
City State
Postal Code Country
Contact Name
Contact Business Phone Number 718-387-7702
INSURED INFORMATION
Insured Name County Agency Inc. insured FEIN 285
insured Type OInsured OSelf-Insured OUninsured Insured Location ID
Policy Number ID | 0146
Policy Effective Date 04/01/2021 Policy Expiration Date 04/01/2022
An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who KNOWINGLY
MAKES A FALSE STATEMENT OR REPRESENTATION as to amaterial fact in the course of reporting, investigation of,
or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such
payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
The above information istrue to the best of my knowledge and belief.
Ifprepared by the employer:
Signature of Person Preparing Form Date 8/30/2021
Print Name Chavy Blum
Title Phone Number
C-2F (1-14) Page of www.wcb.ny.gov
Document Filed Date
August 10, 2022
Case Filing Date
March 09, 2022
Category
Torts - Other Negligence (Premises)
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FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 08/10/2022 EXHIBIT N FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. ° NO. *'s 23 Workers' RECEIVED NYSCEF: 08/10/2022 State of New York - Compensation Board °ª4 Employer's First Report of Work-Related Injury/lliness A work-related injury or illness must be reported within 10 days (Per Section 110) of the injury/illnessor be subject to a penalty. Workers' Employers are not required to submit form C-2F to the Compensation Board if the employer's insurer will be submitting the accident information electronically tothe Board on the employer's behalf. Ifyou need assistance completing this form, please contact your insurer for guidance on the best method of reporting work-related accident information. Ifyou submit thisform to the Board, please send it toP.O. Box 5205, Binghamton, NY 13902 and provide a copy to your insurer. Employee Name Kalween Rodriquez WCB Case Number (JCN) Date of Injury 09/20/2019 Claim Administrator Claim Number INSURER / CLAIM ADMINISTRATOR INFORMATION Insurer Name Oriska Insurance Carrier Insurer ID Name Info/Attn Address 1310 UticaStreet, POB 855 City Oriskany State NY Postal Code 13424 Country Claim Admin ID EMPLOYEE INFORMATION First Name Kalween Middle Name/Initial Last Name Rodriguez Suffix Mailing Address 233 Jamaica Avenue, #1B City Brooklyn State NY Postal Code 11207 Country Phone Number 5604 Date of Hire 10/01/2016 Date of Birth 1684 Gender Male ¡ Female ¡Unknown Employee SSN 014 Occupation Description Superintendent C-2F (1-14) Page of www.wch.ny.gov FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 08/10/2022 CLAIM INFORMATION Time of Injury unknown Date Employer Had Knowledge of the Injury 9/20/2019 Employment Status fulltime Date Employer Had Knowledge of Date of Disability Estimated Weekly Wage 700 Number of Days Worked Per Week 5 Work Week Type O Standard Work Week ¡ Fixed Work Week OVaried Work Week Work Days Scheduled ¡ Sun ¡Mon ¡Tues ¡Wed ¡Thurs ¡Fri ¡ Sat EMPLOYEE INJURY Full Wages Paid for Date of Injury ¡Yes ¡No Employer Paid Salary in Lieu of Compensation ¡Yes ¡No InitialTreatment O No Medical Treatment ¡Minor On-Site Treatment By Employer OMinor Clinic/HospitalTreatment ¡Emergency Evaluation ¡Hospitalization Greater Than 24 Hours OFuture Major Medical/Lost Time Anticipated Death Result of Injury ¡Yes ¡No OUnknown Date of Death Number of Dependents Nature of Injury (ie Laceration, Bums, Fracture,Strain,etc) cut Part of Body (i eleftarm, rightfoot,head, multiple,etc) cheek Cause of injury (i eMotor Vehicle,Machine, Strainor injuryby lifting, etc) Accident/Injury Description (see instructions) employee was in garage and some debris fell on him WORK STATUS InitialDate Last Day Worked n/a Return To Work Type ¡Actual OReleased InitialDate Began Physical Restrictions ¡Yes ¡No Disability InitialReturn to Work Date 09/20/2021 Return To Work Same Employer ¡Yes ¡No ACCIDENT LOCATION AND WITNESSES Premises (see instructions) ¡Employer ¡Lessee ¡Other Organization Name Street State City Postal Code County Country Location Narrative garage Witnesses Business Phone Number C-2F (1-14) Page of www.wcb.ny.gov FILED: KINGS COUNTY CLERK 08/10/2022 03:11 PM INDEX NO. 506931/2022 NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 08/10/2022 EMPLOYER INFORMATION Name County Agency Inc. Employer FEIN 285 UI Number Manual Classification Code Industry Code info/Attn Malling Address 129 S 8 Street City Brooklyn State NY Postal Code 11211 Country Physical Addr City State Postal Code Country Contact Name Contact Business Phone Number 718-387-7702 INSURED INFORMATION Insured Name County Agency Inc. insured FEIN 285 insured Type OInsured OSelf-Insured OUninsured Insured Location ID Policy Number ID | 0146 Policy Effective Date 04/01/2021 Policy Expiration Date 04/01/2022 An employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to amaterial fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. The above information istrue to the best of my knowledge and belief. Ifprepared by the employer: Signature of Person Preparing Form Date 8/30/2021 Print Name Chavy Blum Title Phone Number C-2F (1-14) Page of www.wcb.ny.gov