Preview
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
EXHIBIT “BB”
EXHIBIT “BB”
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
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MCGONIGAL KEVIN
~ I ~I 11? CHRISTIAN ORIVE
I a~ a~ I EAST STROUDSSURG, I A 18301
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7 Gamer THE STATE INSURANCE FUNOI
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FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
THE WORKERS' COMPENSATION STATE OF NEW YORK
BOARD EMPLOYS AND SERVES WORKERS' COMPENSATION BOARD
THE HANDICAPPED WITHOUT EMPLOYER'S STATEMENT OF EARNING S
DISCRIMINATION (Preceding the Date of Accident)
1. W.C.B. Case No. 2. Carrier's Case No. 3. Date of Accident 4. Employee's S.S. No.
00000000 66674078 - 102 09/06/2013 XXX-XX-4776
Name, Address and Zip Code
5. Employer 6. Injured Employee
K.I.M. CO. REFRIGERATION CORP MCGONIGAL KEVIN
D/B/A DAY & NITE REFRIGERATION 117 CHRISTIAN DRIVE
10 CHARLES ST PO BOX 310 EAST STROUDSBURG, PA 18301
NEW HYDE PARK,NY 11040
7. Canier THE STATE INSURANCE FUND
8. Employee was employed at o(n) .................................................................- wage for a .................................... day week.
(flourly,dally,weeklyor montNy) (6,6or7)
9. Was injured employee in military service during the 5 week ceriod immediately orecedina the date of arr.ident? ..........................
If so, Date of Discharge ....................... ......................
|NSTRUCTIONS:
1. Give aross weekht earninae for each of the 52 week neriode immediately orecedina the date of accident.
2. If injured employee has not worked at the same work for a year or a part thereof (234 days for a 5
day week, 270 days for a 6 day week) give the weekly gross earnings of another employee of the sarne
class who has worked for a year or a substantial part thereof immediately preceding the date of accident.
10. The following is a schedule of gross earninas for the 52 wccks immediately preceding the date of pcodent of.
(Check "x" one)
The in emp!oyee n d in item 6 above. f,d)g¿µ
. .. .. 1.LLeut .a .... . o pjg.L,. __. .. .-...... ........ .. .................... . ................................ ....................... ... ... .......
(NEmeof the any oyeeof thesameclass) (Address)
N DATE ED INc I TIME No ATE WR D INc U I OVE N A
'
2 f-ff>f /2 4I., sh C 20 $4 / '7, /f3y do as /¿f7 (
pN'
5 H†fd I & O 23 C/ p
• 30 45 (/ f 93f L/ µ.f s3 (. C
10 P//s 7 a Cf 34 8 0 V /½W oD 52 4/S 4 / Ovp
17 - OL) 35 f 7 7
TOTAL
|1s r/ 4:c7C so (frf «f S 3f-A
11. V'as this employee given free rent lodging, board tips, bonus or oth tr allowa.ice in addition to the above eamings? .. ....... .. . ......
. if yes, state weekly value thereof S........................................
Describe ..................................................................................-...................................................... .................. .....................
st-ja"
12. Was there any wage -.-st made affecting the 52 week period scheduled above?............ . .. .........
If yes, explain ..............................--................................. .... .... ... ........................ ............ ........................... ......... ... .. ... ........ .-
I CERTlFY THAT THE ABOVE IS TRUE AND CORRECT:
....... , . ... . ................ ... ... ..... ..
(Narrieof Em
Dato.............. -. ........... .. .. ....... ...................................,,.,,.. . By .. .. ...... .. . .. . ... ..... ....... ... . ... . ........ . ,
Tel. No. ........... . .. . .. . ..).... Of5cial Title ... ............. . . . .. . .. . . ............
Evelyne Auguste
c-24o (11/o1) PLEASE SEE REVERSE FOR MAILING INSTRUCTI ONS
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
NewYork State Insurance Fund
NYSIlC
[7000-##‡"-""######][102][NEW-CLM-NCSLTR][01-00344]
K.I.M. CO. REFRIGERATION CORP
D9/23/2013
D/B/A DAY & NITE REFRIGERATION
10 CHARLES ST PO BOX 310
NEW HYDE PARK NY 1j040
NYSIF Case Number 66674078-102 Number: 751171 - 0
Policy
Claimant: KEVIN MCGONIGAL Date of Accident: 09/06/2013
Dear Employer:
Please note the information next to the box(es) checked below.
Workers' Injury/lllness"
Your Compensation Board (WCB)form C-2 "Employer's Report of Work-Related
conceming the above captioned case has been received. Please use the above case number on all future
correspondence regarding this matter.
It has come to our attention that the above named employee may havo incurred a work related injury/illness.
To date. we have not yet received your completed C-2, "Employer's Roport of Work-Related Injury/IIIness".
An omployer must file a C-2 with the WCB and NYSIF within ten (10) days of the employer's knowledge of a work-
related injury/illness, provided that the injury/illness has caused or will cause the employee lost time from regular
duties of one (1) day beyond the workday or shift during which the accident occurred; or has required or will require
medical treatment beyond ordinary first aid or more than two (2) trêatrñents by a person rendering first aid.
You may complete a C-2 online at www.nysif.com
Please subrnit your report as soon as possible to facilitate the processing of the claim. If the claim is questionable
or doubtful, please so indicate.
Packet"
The employer must also provide an injured employee with a "Claimant Information at the time of injury or
illness. This packet Is available online at www.nysif.com
If we do not hear from you, it will be necessary for us to proceed in accordance with the WCB Law and its rules and
regulations, based on available information.
NYStF has received a medical bill for ser vices rendered to the above named employec ror an alleged Injury or
illness on the above accid6ñt date, while in the employ of your company. Unless NYSlF is notified to the contrary
within ten (10) days, It will be presumed that the services billed were rendered as a result of an injury/ifiness that is
confirmed by you as arising out of and in the course of employment, and the provider's bill will be piccêssed for
payment.
Respectfully Yours,
..
Evelyne Auguste
Case Manager
Phone: (631) 7564174
Fax: (631)756-4070
0Ÿ0Ï00 4 4 0
8 corporate CenterDr 2nd Floor Melville, NY 11747-3'[66
J/2013)[WCLossID-66674078]Tfacl:
FormEMNNITVersion1(O7/0 U-3,U-3A [00000000000D046644
D0][70 102]NEW-CUW-NCSLTR](0140344}
first
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
Notice to Chair of Carrier's Action on Claim for Benefits EC-669
Workers' Compensation Volunteer Firefighter (
Check Type of Case: (0 ( Volunteer Ambulance Worker
IuLL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS
1. W,C.B. Case Number 2. Carrier Case Number 3, Carrier Code 4. Date of Injury 5 Social Security Number
G0789077 66674078-102 Il204002 Sep 6, 2013 XXX-XXP776
6. Injured Person First Name: KEVIN MCGONIGAL Ml:
Address: 117 CHRISTIAN DRIVE Line 2:
City: EAST STROUDSBURG Stets: PA Zip Code: 18301 Country: USA
7. Employer* Name: K,I.M. CO. REFRIGERATIOhi CORP
Address: D/B/A DAY & MITE REFRIGERATION Line 2.'10 CHARLES ST PO BOX 310
City: NEW HYDE PARK State:NY Zip Code; 11040 Country: USA
8. Carrier Name: THE STATE INSURANCE FUND
Address: Nassau Office Line 2: 8 Corp Ctr Dr, 2nd Fl
City: Melville State: NY Zip Code: 11747-3166 Country. USA
ters' workers'
"ln volunteerfirefigh sod volunteerambulance cases, enterthe liable politicalsubdivision(or uhaffiliatedambulanceserviceas definedia vAwBL) ss the EMpLQYER
9. Description (Diagnosis) of injury:
KNEE RIGHT, KNEE LEFT, SHOULDER RIGHT, SHOULDER LEFT, BACK, NECK.
10. Place where injury occurred: City NEW YORK County: NEW YORK State: NY
11. Date disability began Sep 6, 2013 12. Date erapioyer or carrier ha knowledge of injury, w„lcheverls carlish Sep 6. 2013
13. Date of receipt by carrier of employer's report of injury (c-2, vF-2 or vAw-2) (if none, so state): sep 20, 2013
14. Date returned to work (if applicable):
15. A X CLAIM IS NOT DISPUTED. PAYMENT HAS BEGUN, fComplete Items 1 and 2 below if either 15-A or 15-8 is
selected
—.—
/, TEMPORARY PAYMENT OF COMPENSATION AND PR=-. -D ~ED! C!NE HAS BEGUN WITHOUT PREJUDICE AND WITHOUT
~ ADM)TTING LIABILITY (Sec. 21m WCL)
1. Payment hss begun from: Sep 6. 2013 at a weekly rate of: $725 00 Date first payment mailed: Oct 21, 2013
< Check here if weekly rate shown is a temporary rate subject to adjustinent upon receipt of payroll inf .... ""n and complete section 2 below.
lf the rats is less than the;.—.o,— in effect on the date of the Injury. (yyCL f 5, subd. 6(a)), fhe basis for the c-;„P".'-."-n MUST be enfe/sd ln
„".—.,
item 2 and suppo/ting documents (payroll or other) MUsT be etteched.
Workers'
2. Basis For Computation - Compensation Cases Only
Average Daily Wage: $220.50 X ne. of days worked: 260 = $57,33p.pp
+ 52 = Average Weekly Wage: $1,102.00 X 2/3 Weekly Comp Rats (Subject to Maximum)
If temporary rate indicate basis:
INVESTIGATION
~
~
Check here il payment inarle without prej(>dice. as provided In Sec. 50 Vi BUVAWBL, pending deteiminaiion of political subdivision/vol.
ambuiarice service liable for benefits.
Death Cases' attach list ol payess. showing name and address. relationship to deceased. date of biAh, percentage of award and rate per week lor each
payee. If knowii. Also include name and address of undenakor. amount oi funeral bill, amounl of funeral bill paid end by whom (name snd address)
16- CLAIM IS NOT DISPUTED. PAYMENT HAS NOT BEGUN FOR THE FOLLOWING REASON(S):
firefighters'
a-
[7 No lost time beyond 7 days. (In volunteer and ambulance workers' cases, 7 day waiting period does not apply.)
Q Lost time exceeds 7 days, no medical evidence Indicating disability beyond 7 days. (When such evidenceis svstlshe, centermustcommencepeymsnL)
c. Possible schedule loss or disfigurement, but no loss of time from woik at regular wages beyond 7 days,
d
Q Lost time exceeds 7 days, but full wages being paid by employer during disability,
Q Employer requests reimbursement in the amount of.
e
Q Death case awaifing Information as to dependents. if eny. or dependency proofs - accidental death not conlroverted.
f. Other explanation:
I7. Designated carrier employee (see NYCRR 325-1.4) who receives requests for authorization of special medical services costing more than $1000:
First Name: Evelyne Last Name: Auquste
Telephone No: (631) 7584126
L Workers'
The insurance company will notify the Chair, Compensation Board, and the claimant and hislher
Person Preparing Form: -- --=:==-' -, if any, If benefits are stopped or modified, or of ' —..—.::—
any other change in the above .:
Rrst Name: Evelyne Last Name. Auguste MI.
Officls! Title. Case Manager Telephone No. & Extension; (631) 7564126 Dated: Oct 22, 2013
Prescribedby Chair
EC-669 (1-11) Workers' CompensationBoard
Slate of New York
»V~' I' It
vin/i/M/.wcb sfa te.ny.us
Ii»
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
EMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESS
Workers'
RD State of New York - Compensation Board
\f one of your employees has a workwelated injury or illness, you must counplete and file 1his form within 10 days of the
in]urylillness or be subject to a penaly. For addtdonal information on filing this form please refer to Workers'
Compensation Law Section 110 at theend of this fonn. Type or print nestly.
WCB Case Number (if you knowit): Date of Injury/illness: ÛÊ / DG / / 3
BŸ É
Carrier Case Number (If you know it): __ Date of this Report: Ê Ý / / /
A. EMPLOYER INFORMATION
1. Employer:- •Ó'd. .Employer FEIN: /
3. MallIng Address: I 0 ,4 #24 2 Å)GM) a ( t a ( D
4. I ocalinn Adriress (lf different):
5. Phone Number ( () 4) 3 76 - 6. Nature of Business or Industry Code 4 4- dA R- L.
7.0SHA Case Number (if known): 8. NY Ul Employer Reg Number
B. INSURANCE CARRIER / SELF-INSURED EMPLOYER
If inmvidue!!y self-insuned, enter your Board W Number and skip to Section C.
1.BoardW Number: W 2. Canier/Group Narn
3. Policy Number 1 Ú '
Policy Period: From: I r I ! ( / To:
4. If Carrier Unknown, Insurance Agent Nanw 5. Phone Nurnber 3/ ) o // 3
C. EMPLOYEE'S PERSONAL INFORMATION
1 Name 2. Date of Birth: c / / 7 7
Rm U t.ssi
a Mailing Arldmm I/ 7 tL I S I d& tLow og &.tp- A< i 9 /
4. Social Secuiity Number Ó 5. Contact Phone Number:( 3 /_ 6, Gender Male Female
D. EMPLOYEE'S INJURY C R ILLNESS
L Time ofday employee began work on date of injury: AM L_} PM 2. IIme of injury AM PM
3. Has the employee given you notice of Injury/illness? Yes No
If yes, notice was given to: NW eh /,26S orally U in writing Date notice provided: (Î I I /
If avaHable, attach a copy of the employee's written notice and medical notes, and the employer's incident report.
4. Have you given the employee a Claiment Informa on Packet? U Yes No if yes, give date: / /
5. Where did the injury/Illness happen (e.g., 1 Main St., Pottersville, at the front door):
6. Was this location where the employee normally worked? U Yes No If no, why was the employee there?
7. Ernployee'ssupervisor: v A 6 8. Did supervisor see injury happen? Yes No ¤Unknown
9. Did anyone else see the injury happen? Yes ¤ No Unknown If yes, give narge(s): UAt A. C
10. What was the employee doing when he/she was injured or became ill? (c.g.. unicading tmck. slacking a shelf, typing annual report)
WEM o nmEWES
PEoPLE
C-2.0 (1-11) Page 1 of 3 S
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
EMPLOYEE'S NAME: (JJ / Ã o fh f P DATE OF INJURY/ILLNESS: #Ý / I f 3
D. EMPLOYEE'S INJURY OR ILLNESS cos nued
11. How did the injury/illness occur? (e.g., the emp e tripped over a pipe and fell on theiloor)_ _ ___
12. ExpIsin fully the nature of the employee's injury/illness; Ilst body parts affected (e.g., twisted left ankle and cut to forehead):
13. Was an object (e.g., forklift, hammer, acid) involved in the injury/Illness? ¤ Yes No If yes, what was it?
14. Was the Injury the result of the use or operation of a licensed motor vehlcie? O Yes No ·
If yes, employee's vehicle employefs vehicle D other vehicle license plate number (if known):
If employer's vehicle was involved, give name and address of your motor vehicle insurance carrier:
15. Did the injury/illness result in the employee's death? ¤ Yes 3No If yes, whatwas the date of death? ___.J_1
Name and address of the nearest relative:
. E, MEDICAL TREATMENT
f. What was the date of the ernployee's first treatment? None received O Unknown
2. Where did the employce meeive tkst medical treatmentfor this Injury/lliness? On site O Doctor's office O EmergencyRoom
CIInic/Hospital/Urgent Cate H St o'ar 24 hours Unknown
Who treated the employee and where? & ()eÎM!--5 •
3. Is the employee still being treated for this Injury/lllness? Yes No U Unknown If yes, name and address of treating doctor(s):
4. To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you?
Yes No If yes, name the doctor(s) who treated the previous Injuriessinesses (if known):
F, RETURN TO WORK
1. Did the employee stop work because of his/her injury/illness? Yes ¤No If yes, on what date? / /
2. Has the employee retumed to work? Yes No
If yes, on what date? / regular duty limited duty
3. if the employee has retumed to Ilmited duty, what are his/her average gross earnings per week?
C-2.0 (1-11) Page 2 of 3 w,wcb.ny.gov
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
Ó '' 4(-- fBÓ
EMPLOYEE'S NAME: c o×n DATE OF INJURY/ILLNESS: ÛÝ f/ 3
G. EMPLOYEE'S WORK INFORMATION on the date of the injury or illness
1. Date the employee was hired
2 Whst we the emplnyan's jnh fille?
3. What types of actMtles did the employee no mally pe form at work? (Attach job description if availeblel
H. EMPLOYEE'S PAYROLL INFORMATION on the date of the injury or illness
1. Employee's gross pay in an average week was: $ 3 7- (C
2, Did the employee receive todging or tips in addition lo pay? ¤ Yes No If yes, describe:
3. Employee's job was (check one) Full Time Part Time Seasonal Volunteer 3 Olher N It4/
4, Which days of the week did the érai riss usually work? Moi Tues. Wed. Thurs. Fri. Sat Sun.
5. Was the employee paid for a full day on the day of the injury/illness? Yes No
6. Did you continue fo pay the employee after the Injury/Illness (e.g., sick leave, vacation, disability. regular salary)7 Yes 2 No
I. ADDITIONAL INFORMATION
An employer or carrier, or any employce, agent, or person acting on behalf of ari omployer or carrior, who KNOWINGLY MAKES
A FALSE STATEMENT OR REPRESENTATION as to a materlai 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 previsicñ of such payment or benefit SHALL BE
GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND iTviFiiisüWMENT.
Th ve Information Is true to the best of my knowledge and ballef.
If prepared by the employer:
Signatureof Perso reparingForm Date: ÛÝ /
Print Name: R../ 04 l) Tte chvQdstpty9,¼o'ne . t star 8 n × > 3 r
if prepared by a Titfrd Party on BehaHof ifte E:rripfoyer:
Signatureof PersonPreparingFornt Date: _/.____J
PrintName: ___ Titla·
_ __ _ PhoneNumber:( )
CompanyNameandAddress:
Narne& PhoneNumberof PersonWho ProvidedInformátionNecessaryto PrepareThis Fonre
Workers'
Reports shouki be filed by sendirn directly tothe Compenseba Board at the address below with a copy sent to the insurance carrier:
Workers'
NYS Comoensation Board
Centralized Mailing
PO Box 5205
Binghamton, NY 13902-5205
G-2.0 (1-11) Page 3 of 3 Statewide Fax Une: 877-533-0337 www.wch.ny,gov
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
INSTRUCTIONS TO THE EMPLOYERS
Workers'
Reports should be sent directly to the Corñpensation Board:
Workers'
New York State Compensation Board
Centralized Mailing
PO Box 5205
Binghamton, NY 13902-5205
Statewide Fax Une: 877-533-0337 www.web.ny.gov
THIS AGENCY EMPLOYS AND SERVES PEOPLE WrrH DISABILITIES WITHOUT DISCRIMINATION.
C-11(3/13)ReverseSide
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
s1174731664s
SIF Office
STATE INSURANCE FUND
UNIT 102
8 CORPORATE CENTER DR,
2ND FLOOR, MELVILLE, NY
FOLD ALONG DOTTED LINE AND MAKE SURE SlF ADDRESS FlTS IN WINDOW
......... . .................... .... ...... ...-.............. ..... .. ..... ... -.. . ..... .... ..... .. ... . . .. . .... - .---....-... ......... ...
C-240 (11/01)
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019
wt mns .
t w ys Employee Claim
State of New Yo -
Woriters'
Compensation Board C-3
workers'
Fill out this form to apply for compensation benefits because of e work Mjury or work-related illness. Type or
print neatly. This form may also be filled out o&line at www.wcb.ny.gov.
WCB Case Number (If you know It):
A. YOUR INFORMA N (Employee)
1. Name: -- . . 2. Oste of Birth: / 922
3. Mall
Preview
FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 EXHIBIT “BB” EXHIBIT “BB” FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 I ~ ' 0' ~ 'S ~ =~ ' ~ l' ~ I I ' ~ I' ~ I 7~ ~ '' ~ I ~ ~ ' ll ~ =~ ~ . ~ - ~ ' ~ ~— S- ~ ' vI ~~ I ~I I I I I ~ va ~ ' I ~ I I ~ I XXX-XX-4776 ~~ I ~ ~~ ~~ b. IllJUfee J=rllpl MCGONIGAL KEVIN ~ I ~I 11? CHRISTIAN ORIVE I a~ a~ I EAST STROUDSSURG, I A 18301 ~ i ~ 'I 7 Gamer THE STATE INSURANCE FUNOI I ~, ~~ I ~ ~ I I ~~ ~ ~ ~St ~~ ' 'ai I ~ta-I ~ I ~ 7' ~-' ' ~ a t . ~ ~ =~ ~ . - ~- ~, ~ I ~' ~~: te ~' I aJ+a ~ XI ~~ ~ . ~ ~ ~ I I. l ~: ~ : ~ II ~ , = ~~ . = ~. ~ ~ ~~ - ~ ~' ' ~ . ~ ~ ~ I ~ ~ I ~~ ~ ~. a ~ ~ ~ aa~ ~ - a ~ ~ - ~ - ~ a+a I. I ~ ~I I~i i ~I ~ Xi iI a ~~ w'7 ~I ~i ~~ ~ ~ — ~~ 0 RERRR~RS: ': "-:: --' aslsaHssl~ ~~Ra~~R~& 21 3S I R%~ KR~~ 40 RR~~ ER~W ES~W~ ~w~as 23 24 2S 42 M M 1~% I~W~SS~W~RS~~~~aia 25 M aa~~~~~~~l 2X IE~M~ss~w~sa~M~ IS~~IS~~aE~ IR~M~sa~w IS~M~ saslasasM~ IR~~~ IS~M~ SIE'IIIECM~ ~saassE~ I (~V WO IS~~SS ~~ I I ~I I ~~ ~ I ~' ~~ ~ ~I I I~ I I ~~ ~ ~ II~ . ~ ~ — ~- ~I ~ I I - ~a - ~I ~ ~~ ~ ~ ~~ I~ ~ ~ X i I ~ I I FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 THE WORKERS' COMPENSATION STATE OF NEW YORK BOARD EMPLOYS AND SERVES WORKERS' COMPENSATION BOARD THE HANDICAPPED WITHOUT EMPLOYER'S STATEMENT OF EARNING S DISCRIMINATION (Preceding the Date of Accident) 1. W.C.B. Case No. 2. Carrier's Case No. 3. Date of Accident 4. Employee's S.S. No. 00000000 66674078 - 102 09/06/2013 XXX-XX-4776 Name, Address and Zip Code 5. Employer 6. Injured Employee K.I.M. CO. REFRIGERATION CORP MCGONIGAL KEVIN D/B/A DAY & NITE REFRIGERATION 117 CHRISTIAN DRIVE 10 CHARLES ST PO BOX 310 EAST STROUDSBURG, PA 18301 NEW HYDE PARK,NY 11040 7. Canier THE STATE INSURANCE FUND 8. Employee was employed at o(n) .................................................................- wage for a .................................... day week. (flourly,dally,weeklyor montNy) (6,6or7) 9. Was injured employee in military service during the 5 week ceriod immediately orecedina the date of arr.ident? .......................... If so, Date of Discharge ....................... ...................... |NSTRUCTIONS: 1. Give aross weekht earninae for each of the 52 week neriode immediately orecedina the date of accident. 2. If injured employee has not worked at the same work for a year or a part thereof (234 days for a 5 day week, 270 days for a 6 day week) give the weekly gross earnings of another employee of the sarne class who has worked for a year or a substantial part thereof immediately preceding the date of accident. 10. The following is a schedule of gross earninas for the 52 wccks immediately preceding the date of pcodent of. (Check "x" one) The in emp!oyee n d in item 6 above. f,d)g¿µ . .. .. 1.LLeut .a .... . o pjg.L,. __. .. .-...... ........ .. .................... . ................................ ....................... ... ... ....... (NEmeof the any oyeeof thesameclass) (Address) N DATE ED INc I TIME No ATE WR D INc U I OVE N A ' 2 f-ff>f /2 4I., sh C 20 $4 / '7, /f3y do as /¿f7 ( pN' 5 H†fd I & O 23 C/ p • 30 45 (/ f 93f L/ µ.f s3 (. C 10 P//s 7 a Cf 34 8 0 V /½W oD 52 4/S 4 / Ovp 17 - OL) 35 f 7 7 TOTAL |1s r/ 4:c7C so (frf «f S 3f-A 11. V'as this employee given free rent lodging, board tips, bonus or oth tr allowa.ice in addition to the above eamings? .. ....... .. . ...... . if yes, state weekly value thereof S........................................ Describe ..................................................................................-...................................................... .................. ..................... st-ja" 12. Was there any wage -.-st made affecting the 52 week period scheduled above?............ . .. ......... If yes, explain ..............................--................................. .... .... ... ........................ ............ ........................... ......... ... .. ... ........ .- I CERTlFY THAT THE ABOVE IS TRUE AND CORRECT: ....... , . ... . ................ ... ... ..... .. (Narrieof Em Dato.............. -. ........... .. .. ....... ...................................,,.,,.. . By .. .. ...... .. . .. . ... ..... ....... ... . ... . ........ . , Tel. No. ........... . .. . .. . ..).... Of5cial Title ... ............. . . . .. . .. . . ............ Evelyne Auguste c-24o (11/o1) PLEASE SEE REVERSE FOR MAILING INSTRUCTI ONS FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 NewYork State Insurance Fund NYSIlC [7000-##‡"-""######][102][NEW-CLM-NCSLTR][01-00344] K.I.M. CO. REFRIGERATION CORP D9/23/2013 D/B/A DAY & NITE REFRIGERATION 10 CHARLES ST PO BOX 310 NEW HYDE PARK NY 1j040 NYSIF Case Number 66674078-102 Number: 751171 - 0 Policy Claimant: KEVIN MCGONIGAL Date of Accident: 09/06/2013 Dear Employer: Please note the information next to the box(es) checked below. Workers' Injury/lllness" Your Compensation Board (WCB)form C-2 "Employer's Report of Work-Related conceming the above captioned case has been received. Please use the above case number on all future correspondence regarding this matter. It has come to our attention that the above named employee may havo incurred a work related injury/illness. To date. we have not yet received your completed C-2, "Employer's Roport of Work-Related Injury/IIIness". An omployer must file a C-2 with the WCB and NYSIF within ten (10) days of the employer's knowledge of a work- related injury/illness, provided that the injury/illness has caused or will cause the employee lost time from regular duties of one (1) day beyond the workday or shift during which the accident occurred; or has required or will require medical treatment beyond ordinary first aid or more than two (2) trêatrñents by a person rendering first aid. You may complete a C-2 online at www.nysif.com Please subrnit your report as soon as possible to facilitate the processing of the claim. If the claim is questionable or doubtful, please so indicate. Packet" The employer must also provide an injured employee with a "Claimant Information at the time of injury or illness. This packet Is available online at www.nysif.com If we do not hear from you, it will be necessary for us to proceed in accordance with the WCB Law and its rules and regulations, based on available information. NYStF has received a medical bill for ser vices rendered to the above named employec ror an alleged Injury or illness on the above accid6ñt date, while in the employ of your company. Unless NYSlF is notified to the contrary within ten (10) days, It will be presumed that the services billed were rendered as a result of an injury/ifiness that is confirmed by you as arising out of and in the course of employment, and the provider's bill will be piccêssed for payment. Respectfully Yours, .. Evelyne Auguste Case Manager Phone: (631) 7564174 Fax: (631)756-4070 0Ÿ0Ï00 4 4 0 8 corporate CenterDr 2nd Floor Melville, NY 11747-3'[66 J/2013)[WCLossID-66674078]Tfacl: FormEMNNITVersion1(O7/0 U-3,U-3A [00000000000D046644 D0][70 102]NEW-CUW-NCSLTR](0140344} first FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 Notice to Chair of Carrier's Action on Claim for Benefits EC-669 Workers' Compensation Volunteer Firefighter ( Check Type of Case: (0 ( Volunteer Ambulance Worker IuLL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W,C.B. Case Number 2. Carrier Case Number 3, Carrier Code 4. Date of Injury 5 Social Security Number G0789077 66674078-102 Il204002 Sep 6, 2013 XXX-XXP776 6. Injured Person First Name: KEVIN MCGONIGAL Ml: Address: 117 CHRISTIAN DRIVE Line 2: City: EAST STROUDSBURG Stets: PA Zip Code: 18301 Country: USA 7. Employer* Name: K,I.M. CO. REFRIGERATIOhi CORP Address: D/B/A DAY & MITE REFRIGERATION Line 2.'10 CHARLES ST PO BOX 310 City: NEW HYDE PARK State:NY Zip Code; 11040 Country: USA 8. Carrier Name: THE STATE INSURANCE FUND Address: Nassau Office Line 2: 8 Corp Ctr Dr, 2nd Fl City: Melville State: NY Zip Code: 11747-3166 Country. USA ters' workers' "ln volunteerfirefigh sod volunteerambulance cases, enterthe liable politicalsubdivision(or uhaffiliatedambulanceserviceas definedia vAwBL) ss the EMpLQYER 9. Description (Diagnosis) of injury: KNEE RIGHT, KNEE LEFT, SHOULDER RIGHT, SHOULDER LEFT, BACK, NECK. 10. Place where injury occurred: City NEW YORK County: NEW YORK State: NY 11. Date disability began Sep 6, 2013 12. Date erapioyer or carrier ha knowledge of injury, w„lcheverls carlish Sep 6. 2013 13. Date of receipt by carrier of employer's report of injury (c-2, vF-2 or vAw-2) (if none, so state): sep 20, 2013 14. Date returned to work (if applicable): 15. A X CLAIM IS NOT DISPUTED. PAYMENT HAS BEGUN, fComplete Items 1 and 2 below if either 15-A or 15-8 is selected —.— /, TEMPORARY PAYMENT OF COMPENSATION AND PR=-. -D ~ED! C!NE HAS BEGUN WITHOUT PREJUDICE AND WITHOUT ~ ADM)TTING LIABILITY (Sec. 21m WCL) 1. Payment hss begun from: Sep 6. 2013 at a weekly rate of: $725 00 Date first payment mailed: Oct 21, 2013 < Check here if weekly rate shown is a temporary rate subject to adjustinent upon receipt of payroll inf .... ""n and complete section 2 below. lf the rats is less than the;.—.o,— in effect on the date of the Injury. (yyCL f 5, subd. 6(a)), fhe basis for the c-;„P".'-."-n MUST be enfe/sd ln „".—., item 2 and suppo/ting documents (payroll or other) MUsT be etteched. Workers' 2. Basis For Computation - Compensation Cases Only Average Daily Wage: $220.50 X ne. of days worked: 260 = $57,33p.pp + 52 = Average Weekly Wage: $1,102.00 X 2/3 Weekly Comp Rats (Subject to Maximum) If temporary rate indicate basis: INVESTIGATION ~ ~ Check here il payment inarle without prej(>dice. as provided In Sec. 50 Vi BUVAWBL, pending deteiminaiion of political subdivision/vol. ambuiarice service liable for benefits. Death Cases' attach list ol payess. showing name and address. relationship to deceased. date of biAh, percentage of award and rate per week lor each payee. If knowii. Also include name and address of undenakor. amount oi funeral bill, amounl of funeral bill paid end by whom (name snd address) 16- CLAIM IS NOT DISPUTED. PAYMENT HAS NOT BEGUN FOR THE FOLLOWING REASON(S): firefighters' a- [7 No lost time beyond 7 days. (In volunteer and ambulance workers' cases, 7 day waiting period does not apply.) Q Lost time exceeds 7 days, no medical evidence Indicating disability beyond 7 days. (When such evidenceis svstlshe, centermustcommencepeymsnL) c. Possible schedule loss or disfigurement, but no loss of time from woik at regular wages beyond 7 days, d Q Lost time exceeds 7 days, but full wages being paid by employer during disability, Q Employer requests reimbursement in the amount of. e Q Death case awaifing Information as to dependents. if eny. or dependency proofs - accidental death not conlroverted. f. Other explanation: I7. Designated carrier employee (see NYCRR 325-1.4) who receives requests for authorization of special medical services costing more than $1000: First Name: Evelyne Last Name: Auquste Telephone No: (631) 7584126 L Workers' The insurance company will notify the Chair, Compensation Board, and the claimant and hislher Person Preparing Form: -- --=:==-' -, if any, If benefits are stopped or modified, or of ' —..—.::— any other change in the above .: Rrst Name: Evelyne Last Name. Auguste MI. Officls! Title. Case Manager Telephone No. & Extension; (631) 7564126 Dated: Oct 22, 2013 Prescribedby Chair EC-669 (1-11) Workers' CompensationBoard Slate of New York »V~' I' It vin/i/M/.wcb sfa te.ny.us Ii» FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 EMPLOYER'S REPORT OF WORK-RELATED INJURY/ILLNESS Workers' RD State of New York - Compensation Board \f one of your employees has a workwelated injury or illness, you must counplete and file 1his form within 10 days of the in]urylillness or be subject to a penaly. For addtdonal information on filing this form please refer to Workers' Compensation Law Section 110 at theend of this fonn. Type or print nestly. WCB Case Number (if you knowit): Date of Injury/illness: ÛÊ / DG / / 3 BŸ É Carrier Case Number (If you know it): __ Date of this Report: Ê Ý / / / A. EMPLOYER INFORMATION 1. Employer:- •Ó'd. .Employer FEIN: / 3. MallIng Address: I 0 ,4 #24 2 Å)GM) a ( t a ( D 4. I ocalinn Adriress (lf different): 5. Phone Number ( () 4) 3 76 - 6. Nature of Business or Industry Code 4 4- dA R- L. 7.0SHA Case Number (if known): 8. NY Ul Employer Reg Number B. INSURANCE CARRIER / SELF-INSURED EMPLOYER If inmvidue!!y self-insuned, enter your Board W Number and skip to Section C. 1.BoardW Number: W 2. Canier/Group Narn 3. Policy Number 1 Ú ' Policy Period: From: I r I ! ( / To: 4. If Carrier Unknown, Insurance Agent Nanw 5. Phone Nurnber 3/ ) o // 3 C. EMPLOYEE'S PERSONAL INFORMATION 1 Name 2. Date of Birth: c / / 7 7 Rm U t.ssi a Mailing Arldmm I/ 7 tL I S I d& tLow og &.tp- A< i 9 / 4. Social Secuiity Number Ó 5. Contact Phone Number:( 3 /_ 6, Gender Male Female D. EMPLOYEE'S INJURY C R ILLNESS L Time ofday employee began work on date of injury: AM L_} PM 2. IIme of injury AM PM 3. Has the employee given you notice of Injury/illness? Yes No If yes, notice was given to: NW eh /,26S orally U in writing Date notice provided: (Î I I / If avaHable, attach a copy of the employee's written notice and medical notes, and the employer's incident report. 4. Have you given the employee a Claiment Informa on Packet? U Yes No if yes, give date: / / 5. Where did the injury/Illness happen (e.g., 1 Main St., Pottersville, at the front door): 6. Was this location where the employee normally worked? U Yes No If no, why was the employee there? 7. Ernployee'ssupervisor: v A 6 8. Did supervisor see injury happen? Yes No ¤Unknown 9. Did anyone else see the injury happen? Yes ¤ No Unknown If yes, give narge(s): UAt A. C 10. What was the employee doing when he/she was injured or became ill? (c.g.. unicading tmck. slacking a shelf, typing annual report) WEM o nmEWES PEoPLE C-2.0 (1-11) Page 1 of 3 S FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 EMPLOYEE'S NAME: (JJ / à o fh f P DATE OF INJURY/ILLNESS: #Ý / I f 3 D. EMPLOYEE'S INJURY OR ILLNESS cos nued 11. How did the injury/illness occur? (e.g., the emp e tripped over a pipe and fell on theiloor)_ _ ___ 12. ExpIsin fully the nature of the employee's injury/illness; Ilst body parts affected (e.g., twisted left ankle and cut to forehead): 13. Was an object (e.g., forklift, hammer, acid) involved in the injury/Illness? ¤ Yes No If yes, what was it? 14. Was the Injury the result of the use or operation of a licensed motor vehlcie? O Yes No · If yes, employee's vehicle employefs vehicle D other vehicle license plate number (if known): If employer's vehicle was involved, give name and address of your motor vehicle insurance carrier: 15. Did the injury/illness result in the employee's death? ¤ Yes 3No If yes, whatwas the date of death? ___.J_1 Name and address of the nearest relative: . E, MEDICAL TREATMENT f. What was the date of the ernployee's first treatment? None received O Unknown 2. Where did the employce meeive tkst medical treatmentfor this Injury/lliness? On site O Doctor's office O EmergencyRoom CIInic/Hospital/Urgent Cate H St o'ar 24 hours Unknown Who treated the employee and where? & ()eÎM!--5 • 3. Is the employee still being treated for this Injury/lllness? Yes No U Unknown If yes, name and address of treating doctor(s): 4. To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you? Yes No If yes, name the doctor(s) who treated the previous Injuriessinesses (if known): F, RETURN TO WORK 1. Did the employee stop work because of his/her injury/illness? Yes ¤No If yes, on what date? / / 2. Has the employee retumed to work? Yes No If yes, on what date? / regular duty limited duty 3. if the employee has retumed to Ilmited duty, what are his/her average gross earnings per week? C-2.0 (1-11) Page 2 of 3 w,wcb.ny.gov FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 Ó '' 4(-- fBÓ EMPLOYEE'S NAME: c o×n DATE OF INJURY/ILLNESS: ÛÝ f/ 3 G. EMPLOYEE'S WORK INFORMATION on the date of the injury or illness 1. Date the employee was hired 2 Whst we the emplnyan's jnh fille? 3. What types of actMtles did the employee no mally pe form at work? (Attach job description if availeblel H. EMPLOYEE'S PAYROLL INFORMATION on the date of the injury or illness 1. Employee's gross pay in an average week was: $ 3 7- (C 2, Did the employee receive todging or tips in addition lo pay? ¤ Yes No If yes, describe: 3. Employee's job was (check one) Full Time Part Time Seasonal Volunteer 3 Olher N It4/ 4, Which days of the week did the érai riss usually work? Moi Tues. Wed. Thurs. Fri. Sat Sun. 5. Was the employee paid for a full day on the day of the injury/illness? Yes No 6. Did you continue fo pay the employee after the Injury/Illness (e.g., sick leave, vacation, disability. regular salary)7 Yes 2 No I. ADDITIONAL INFORMATION An employer or carrier, or any employce, agent, or person acting on behalf of ari omployer or carrior, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a materlai 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 previsicñ of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND iTviFiiisüWMENT. Th ve Information Is true to the best of my knowledge and ballef. If prepared by the employer: Signatureof Perso reparingForm Date: ÛÝ / Print Name: R../ 04 l) Tte chvQdstpty9,¼o'ne . t star 8 n × > 3 r if prepared by a Titfrd Party on BehaHof ifte E:rripfoyer: Signatureof PersonPreparingFornt Date: _/.____J PrintName: ___ Titla· _ __ _ PhoneNumber:( ) CompanyNameandAddress: Narne& PhoneNumberof PersonWho ProvidedInformátionNecessaryto PrepareThis Fonre Workers' Reports shouki be filed by sendirn directly tothe Compenseba Board at the address below with a copy sent to the insurance carrier: Workers' NYS Comoensation Board Centralized Mailing PO Box 5205 Binghamton, NY 13902-5205 G-2.0 (1-11) Page 3 of 3 Statewide Fax Une: 877-533-0337 www.wch.ny,gov FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 INSTRUCTIONS TO THE EMPLOYERS Workers' Reports should be sent directly to the Corñpensation Board: Workers' New York State Compensation Board Centralized Mailing PO Box 5205 Binghamton, NY 13902-5205 Statewide Fax Une: 877-533-0337 www.web.ny.gov THIS AGENCY EMPLOYS AND SERVES PEOPLE WrrH DISABILITIES WITHOUT DISCRIMINATION. C-11(3/13)ReverseSide FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 s1174731664s SIF Office STATE INSURANCE FUND UNIT 102 8 CORPORATE CENTER DR, 2ND FLOOR, MELVILLE, NY FOLD ALONG DOTTED LINE AND MAKE SURE SlF ADDRESS FlTS IN WINDOW ......... . .................... .... ...... ...-.............. ..... .. ..... ... -.. . ..... .... ..... .. ... . . .. . .... - .---....-... ......... ... C-240 (11/01) FILED: NEW YORK COUNTY CLERK 07/18/2019 04:15 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 315 RECEIVED NYSCEF: 07/18/2019 wt mns . t w ys Employee Claim State of New Yo - Woriters' Compensation Board C-3 workers' Fill out this form to apply for compensation benefits because of e work Mjury or work-related illness. Type or print neatly. This form may also be filled out o&line at www.wcb.ny.gov. WCB Case Number (If you know It): A. YOUR INFORMA N (Employee) 1. Name: -- . . 2. Oste of Birth: / 922 3. Mall