On September 12, 2013 a
Exhibit,Appendix
was filed
involving a dispute between
Kevin Mcgonigal,
and
Baring Industries, Inc.,
Nyy Steak Manhattan, Llc,
Plaza Construction Corp.,
for Tort
in the District Court of New York County.
Preview
FILED: NEW YORK COUNTY CLERK 04/16/2019 03:55 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 271 RECEIVED NYSCEF: 04/16/2019
Exhibit F
FILED: NEW YORK COUNTY CLERK 04/16/2019 03:55 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 271 RECEIVED NYSCEF: 04/16/2019
WQRKiEtS'
tggw RD
Employee
-Workers'
Claim
C-3
State of New York Compertsation Board
workers'
Fill out this forrn to apply for compensation benefits because of a work injury or work-related illness. Type or
print neatly. This form may also be filled out on-line at www.wcb.ny.gov.
WCB Case Number (If you know it):
A. YOUR INFORMA ON (Employee)
1. Name 7A^ . ..__ _____. 2. Date of Birth: _ _
3. Mailing address: // .___Û/f215Â7J . 7 77¿D S?Tu? G
4. Social Security Numben . 5. Phone Number: ( ) . 6. Gender: le D Female
7. Will youneed a translator11you have to attend Board hearing? Yes O No I es, for what language? _....__
B. YOUR EMPLOYER(S)
1. Employerwhen injured: .__ .... f5'fM~TiryN 2. Phone Number: L. . ..L. ... . . .__. .,
3. Your work address: _........ .. .
4. Date you were hired: I 5 Yoursupervisor's name:............... ¬. . .....
6. Listnames/addresses of any other emp rier(s) at the time of your injury/illness: --.- -. .---. -----..----
..--.__-....__-....._..-..........-.....-._...._.-....-._.,.............. . ...... ..-..__... .-
7. Did you lose time from work at the otherempkyment(s) as aresult of yourinj s Yes o
C. YOUR JOB on the date of the injury or illness
1. What was your jobtitle ordescription? _____...
2. What types of activities did you normally perform at worko
Ced S 772 a c T o
3. Was your job? (check one) ITime Part Time Seasonal Volunteer ¤ Other__.__
4. What was your gross pay (beforetaxes) per pay period?. .. 5. How often were you paid?
6. Did you receive lodging or tips in addition to your pay? O Yes No If yes, describe:... ....__._.__._... ... ...... ...........
D. YOUR INJURY OR ILLNESS
1. Date of injury or date of onset of illness; / .JÓ-- 2. Time of injury: - PM
3. Where did the in urylillness happen? (e.g., 1 Main Street, Pottersville, at the front door)__ . ...Ó.
4. Was this your usual work location? es No If no, why were you at this locat on?
5. What were you doing when you were injured or became ill? (e.g., unloading a truck. lyping areport) _..
6. How did the injury/i"nc= happen? (e.g., I tripped over e pipe and fell on the floor) .... ... ..... ..- .__._.. .
7. Explain fully the nature of you urj ness; list body parts affected (e.g., twisted left ank e and cut to o eheadt
.....__..._
C-3.0 (1-11) Page 1 of 2 wnesses ou a www.wcb.ny.gov
|M
Defendant's Exhibit
For identification
FILED: NEW YORK COUNTY CLERK 04/16/2019 03:55 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 271 RECEIVED NYSCEF: 04/16/2019
YOUR NAME: ...
qu
..
tÄf
..._..
LU51
DATE OF INJURY/lLLNESS: .. _./....Î ) Å
D. YOUR INJURY OR ILLNESS continued
8. Was an object (e.g., forklift, hammer, acid) Involvedin the injury/illness? Yes If yes, what? __... . ......._
_,,..._. .
9. Was the injury the result of the use or operation of a licensed motor vehicle? Yes C No
If yes, your vehicle O employer'svehicle O other vehicle License plate number (if knowr‡ .- ..._.
If your vehicle was involved, give name and address of your motor vehicle insurancecarrier: ___..__,_ __ ______
10. Have you given your employer (or supervisor) notice of injury/illness? O Yes O No
If yes, notice was given to: ...___._. _.._._...... __..._.-.- D in writing Date notice given:s/. i .
Oorally
~
11. Did anyone see your injury happen? es O No Unknown If yes, list names:.
E. RETURN TO WORK
1. Did you stop work because of your injury/illness? Yes, on what date? _._..L___/__ O No, skip to SectionF.
2. Have you retumed to work? Yes N yes. on what date? /_.-J___ . regularduty limitedduty
3. If you have returned to work, who are you working for now? O Same employer New employer D Self employed
4. What is your gross pay (before taxes) per pay period? How often are you paid9
F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
1, What was the date of your first treatment?_3. None received (skip to question F-5)
2. Were you (reated on site? O Yes No
3. Where did you receive your first off site medical treatmentfor your .;rf/ asa? Onone received C EmergencyRoom
O Doctor's office Clinic!HospitaUUrgentCare O Hospital Stay over 24 hours
Nameand address where you were first treated: O( 5d. OP _.....
4 .... - .0 4.·v - Phone Number: (___) __.____
4. Are you still being treated for this injury/illness? es No
Give the name and address of the doctor(s) treating you for this injury/illness: ....._ .___..... .
. .. Phone Number: ( )____....
5. Do you remember having another injury to the same body part or a similar mness? Yes No
if yes, were you treated by a doctor? O Yes ¤No If yes, provide the namesand addresses of the doctor(s) who treated
you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:
6. Was the previous injury/illness work relate Y N
If yes, were you working for the same employer that you work for now? Yes No
I am herebyiniking a claim for benefits under the Workers"Compen::!!;:: Law. My signatureaffirms that the i± n ) am providingis true
of
andaccurateto the best my knowledgeondbelief,
Arl p.orsonwho knowin ly añEf HiliMEÑf TÖ Î3ÏffhÄÛEEgfusontgcausesto be presented.,or 3ro>areswnh knowledre oiTëifoTlli
wil he resented to or . ..an insurer' , or spifsinsure,:any-ndGñJwi eqntainin any FALSE AT RIAt. STATEMEN or concealsany
a AM. BE U. ILTY0F CRTMEand subjeg tosuI)s1#tel FINESAW INrniSGiñiENT.
mployeesSignature: Ó PrintName: . ... . ....................__...__....___...__....Date:_/_/-___.
OnbehalfoiErnployee· Print N;ime:. _-- ..........,.. .........._._.__,... .... Date: I J,._
An individualmaysign onbehattof theemployeeonly11heor sheis legallyaufhorizedto dosoandtheemployee is a minor,rnentallyincompetent arine püi!
Tce y Yoilie esÏ oÎ my ib owiedge, oforniationanÛbelief,forñd äficiai nqdy ÎbilsoÁatSuiÜiertiÃcÄnunÖÑëcs. IN alegaÜ0âÜdëo\e
mhtlersassettedabovehaveevidentiarysupport,or are likelyto haveovidenley suppofI arima scanonalkopporWnityfor Isther Dwer,tmations
or dscovery
Signatureof Attomey/Representative
(if any) Date: ! I
oseph A. Rornano Esq . Attorney at Law
PrintNatre.
ID No.,if any: R .. ............ LicenseNo
. ......... II LicensedRepresentative, pirationDate: I___1
C-3.0 (1-11) Page 2 of 2
Document Filed Date
April 16, 2019
Case Filing Date
September 12, 2013
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED: NEW YORK COUNTY CLERK 04/16/2019 03:55 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 271 RECEIVED NYSCEF: 04/16/2019 Exhibit F FILED: NEW YORK COUNTY CLERK 04/16/2019 03:55 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 271 RECEIVED NYSCEF: 04/16/2019 WQRKiEtS' tggw RD Employee -Workers' Claim C-3 State of New York Compertsation Board workers' Fill out this forrn to apply for compensation benefits because of a work injury or work-related illness. Type or print neatly. This form may also be filled out on-line at www.wcb.ny.gov. WCB Case Number (If you know it): A. YOUR INFORMA ON (Employee) 1. Name 7A^ . ..__ _____. 2. Date of Birth: _ _ 3. Mailing address: // .___Û/f215Â7J . 7 77¿D S?Tu? G 4. Social Security Numben . 5. Phone Number: ( ) . 6. Gender: le D Female 7. Will youneed a translator11you have to attend Board hearing? Yes O No I es, for what language? _....__ B. YOUR EMPLOYER(S) 1. Employerwhen injured: .__ .... f5'fM~TiryN 2. Phone Number: L. . ..L. ... . . .__. ., 3. Your work address: _........ .. . 4. Date you were hired: I 5 Yoursupervisor's name:............... ¬. . ..... 6. Listnames/addresses of any other emp rier(s) at the time of your injury/illness: --.- -. .---. -----..---- ..--.__-....__-....._..-..........-.....-._...._.-....-._.,.............. . ...... ..-..__... .- 7. Did you lose time from work at the otherempkyment(s) as aresult of yourinj s Yes o C. YOUR JOB on the date of the injury or illness 1. What was your jobtitle ordescription? _____... 2. What types of activities did you normally perform at worko Ced S 772 a c T o 3. Was your job? (check one) ITime Part Time Seasonal Volunteer ¤ Other__.__ 4. What was your gross pay (beforetaxes) per pay period?. .. 5. How often were you paid? 6. Did you receive lodging or tips in addition to your pay? O Yes No If yes, describe:... ....__._.__._... ... ...... ........... D. YOUR INJURY OR ILLNESS 1. Date of injury or date of onset of illness; / .JÓ-- 2. Time of injury: - PM 3. Where did the in urylillness happen? (e.g., 1 Main Street, Pottersville, at the front door)__ . ...Ó. 4. Was this your usual work location? es No If no, why were you at this locat on? 5. What were you doing when you were injured or became ill? (e.g., unloading a truck. lyping areport) _.. 6. How did the injury/i"nc= happen? (e.g., I tripped over e pipe and fell on the floor) .... ... ..... ..- .__._.. . 7. Explain fully the nature of you urj ness; list body parts affected (e.g., twisted left ank e and cut to o eheadt .....__..._ C-3.0 (1-11) Page 1 of 2 wnesses ou a www.wcb.ny.gov |M Defendant's Exhibit For identification FILED: NEW YORK COUNTY CLERK 04/16/2019 03:55 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 271 RECEIVED NYSCEF: 04/16/2019 YOUR NAME: ... qu .. tÄf ..._.. LU51 DATE OF INJURY/lLLNESS: .. _./....Î ) Å D. YOUR INJURY OR ILLNESS continued 8. Was an object (e.g., forklift, hammer, acid) Involvedin the injury/illness? Yes If yes, what? __... . ......._ _,,..._. . 9. Was the injury the result of the use or operation of a licensed motor vehicle? Yes C No If yes, your vehicle O employer'svehicle O other vehicle License plate number (if knowr‡ .- ..._. If your vehicle was involved, give name and address of your motor vehicle insurancecarrier: ___..__,_ __ ______ 10. Have you given your employer (or supervisor) notice of injury/illness? O Yes O No If yes, notice was given to: ...___._. _.._._...... __..._.-.- D in writing Date notice given:s/. i . Oorally ~ 11. Did anyone see your injury happen? es O No Unknown If yes, list names:. E. RETURN TO WORK 1. Did you stop work because of your injury/illness? Yes, on what date? _._..L___/__ O No, skip to SectionF. 2. Have you retumed to work? Yes N yes. on what date? /_.-J___ . regularduty limitedduty 3. If you have returned to work, who are you working for now? O Same employer New employer D Self employed 4. What is your gross pay (before taxes) per pay period? How often are you paid9 F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS 1, What was the date of your first treatment?_3. None received (skip to question F-5) 2. Were you (reated on site? O Yes No 3. Where did you receive your first off site medical treatmentfor your .;rf/ asa? Onone received C EmergencyRoom O Doctor's office Clinic!HospitaUUrgentCare O Hospital Stay over 24 hours Nameand address where you were first treated: O( 5d. OP _..... 4 .... - .0 4.·v - Phone Number: (___) __.____ 4. Are you still being treated for this injury/illness? es No Give the name and address of the doctor(s) treating you for this injury/illness: ....._ .___..... . . .. Phone Number: ( )____.... 5. Do you remember having another injury to the same body part or a similar mness? Yes No if yes, were you treated by a doctor? O Yes ¤No If yes, provide the namesand addresses of the doctor(s) who treated you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM: 6. Was the previous injury/illness work relate Y N If yes, were you working for the same employer that you work for now? Yes No I am herebyiniking a claim for benefits under the Workers"Compen::!!;:: Law. My signatureaffirms that the i± n ) am providingis true of andaccurateto the best my knowledgeondbelief, Arl p.orsonwho knowin ly añEf HiliMEÑf TÖ Î3ÏffhÄÛEEgfusontgcausesto be presented.,or 3ro>areswnh knowledre oiTëifoTlli wil he resented to or . ..an insurer' , or spifsinsure,:any-ndGñJwi eqntainin any FALSE AT RIAt. STATEMEN or concealsany a AM. BE U. ILTY0F CRTMEand subjeg tosuI)s1#tel FINESAW INrniSGiñiENT. mployeesSignature: Ó PrintName: . ... . ....................__...__....___...__....Date:_/_/-___. OnbehalfoiErnployee· Print N;ime:. _-- ..........,.. .........._._.__,... .... Date: I J,._ An individualmaysign onbehattof theemployeeonly11heor sheis legallyaufhorizedto dosoandtheemployee is a minor,rnentallyincompetent arine püi! Tce y Yoilie esÏ oÎ my ib owiedge, oforniationanÛbelief,forñd äficiai nqdy ÎbilsoÁatSuiÜiertiÃcÄnunÖÑëcs. IN alegaÜ0âÜdëo\e mhtlersassettedabovehaveevidentiarysupport,or are likelyto haveovidenley suppofI arima scanonalkopporWnityfor Isther Dwer,tmations or dscovery Signatureof Attomey/Representative (if any) Date: ! I oseph A. Rornano Esq . Attorney at Law PrintNatre. ID No.,if any: R .. ............ LicenseNo . ......... II LicensedRepresentative, pirationDate: I___1 C-3.0 (1-11) Page 2 of 2