Preview
FILED: NEW YORK COUNTY CLERK 09/16/2019 04:20 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 420 RECEIVED NYSCEF: 09/16/2019
tt7't
Exhibit
FILED: NEW YORK COUNTY CLERK 09/16/2019 04:20 PM INDEX NO. 158327/2013
NYSCEF DOC. NO. 420 RECEIVED NYSCEF: 09/16/2019
wr)rtKt;r{s'
Clorr4t'IN-9,u"tc'rN
'i1ffi$ffi:iiB.cnrrir
Employee
,Sfafe of tVew Yoi* . W6r*ers, Compensailon
ClaimBoard ,4 q
U -r)
Fill out this form t.o apply for.workers.'compensalion beneflts becluse
of a work injury or work+elated illness. Type or
print neatly, This form may also be filled oul on-line at www.wcb,ny.gov.
WCB Case Number (lf you know itlr
A. YOUR
1. Nams; -.
(Fmployee)
sk^r 2. Dare oraith: *8*t 79 tzz,
.3
3. Mailing address: {rzt,t r* beCs}'
4, Social Security s, pnoner'rumol ,,6/1. Wffa, ! Female
7. Will you need a translator if you have lo attendp Board
L] No tf.ves, for what tanouaoe?
hoElng?- [_l Ves
B, YOUREMPLOYER(S)
\. , ,(h"'tc*, K€?'$'utn'ano,'J)
1, Emploverwhon iniwed:
---ffi.*l ill#-f ,ffiCffitZan 2, phone Number:{, . .. )..
3. Your work address: *^."-..*,.
Sksl cdJ
'+r'oF;r$ Sttn I)pCo{o
4, Dateyouwere nraa:
-E&f,1]--. 5. Yoursupervisor! name:
L Oid you lose time fom work at lhe other €mployment{s) as a result of your injury/lllness?
C. YOUR JOB on the date of the injury or illness
ilves flo
1 , Whal wau your job title or description? €rzfua 7=.f7F*
2, What types ol ectivilies dld you normally perlorm at (Ar-1 5 7lZ._r 6.7.,on-f
3. Wasyourjob? (checkone) #*ryr*, f part Time f] seasonal I votunteer il
4, What was your gross pay (before texes) per pay period? bz 5, How oflen were vou oei(J?
ottter:..___
LJYgk"L,
...
6, Did you receive lodging or tips in addilion to your pay? fl y., druo tf yes, descdbe:..
D, YOUR INJURY OR ILLNESS
1. Dale of injury or date of onset ol illness; J-, J *t13- --8": E .p. ffil,1 tr pru
z, Time or injury:
3, Iryhere did the happen? (e.9., 1 Main Street, Potiersville, at the front ooo,)-""-&15g"U"*. /evsz r
UtF \€ t^J sf Er,
4. Was this your usual work localion? Zf.. D No lf no, why were you atthis loca{lon? . . .
5. What wote you doing when you were injured or became iil? (e.g. , unloading a kuck,
..".... c/,{_r r feB
{
6. How did the injurylillness happen? (e.g., I tripp€d over a pipe and fell on the lloor)
fu"/arm^/k"fu,{ , *pYf c.rft. brXArt //r*"fl*{*
",?fr:?.tu/e? .*dfue hu u, /tr;Arri"t +
T. Explain lully the nature of your injuryiillnes$i list body parts affected (e.g,, lwisted left ankle
.. and cut to icrehearJ).
. ilm& f?n
Preview
FILED: NEW YORK COUNTY CLERK 09/16/2019 04:20 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 420 RECEIVED NYSCEF: 09/16/2019 tt7't Exhibit FILED: NEW YORK COUNTY CLERK 09/16/2019 04:20 PM INDEX NO. 158327/2013 NYSCEF DOC. NO. 420 RECEIVED NYSCEF: 09/16/2019 wr)rtKt;r{s' Clorr4t'IN-9,u"tc'rN 'i1ffi$ffi:iiB.cnrrir Employee ,Sfafe of tVew Yoi* . W6r*ers, Compensailon ClaimBoard ,4 q U -r) Fill out this form t.o apply for.workers.'compensalion beneflts becluse of a work injury or work+elated illness. Type or print neatly, This form may also be filled oul on-line at www.wcb,ny.gov. WCB Case Number (lf you know itlr A. YOUR 1. Nams; -. (Fmployee) sk^r 2. Dare oraith: *8*t 79 tzz, .3 3. Mailing address: {rzt,t r* beCs}' 4, Social Security s, pnoner'rumol ,,6/1. Wffa, ! Female 7. Will you need a translator if you have lo attendp Board L] No tf.ves, for what tanouaoe? hoElng?- [_l Ves B, YOUREMPLOYER(S) \. , ,(h"'tc*, K€?'$'utn'ano,'J) 1, Emploverwhon iniwed: ---ffi.*l ill#-f ,ffiCffitZan 2, phone Number:{, . .. ).. 3. Your work address: *^."-..*,. Sksl cdJ '+r'oF;r$ Sttn I)pCo{o 4, Dateyouwere nraa: -E&f,1]--. 5. Yoursupervisor! name: L Oid you lose time fom work at lhe other €mployment{s) as a result of your injury/lllness? C. YOUR JOB on the date of the injury or illness ilves flo 1 , Whal wau your job title or description? €rzfua 7=.f7F* 2, What types ol ectivilies dld you normally perlorm at (Ar-1 5 7lZ._r 6.7.,on-f 3. Wasyourjob? (checkone) #*ryr*, f part Time f] seasonal I votunteer il 4, What was your gross pay (before texes) per pay period? bz 5, How oflen were vou oei(J? ottter:..___ LJYgk"L, ... 6, Did you receive lodging or tips in addilion to your pay? fl y., druo tf yes, descdbe:.. D, YOUR INJURY OR ILLNESS 1. Dale of injury or date of onset ol illness; J-, J *t13- --8": E .p. ffil,1 tr pru z, Time or injury: 3, Iryhere did the happen? (e.9., 1 Main Street, Potiersville, at the front ooo,)-""-&15g"U"*. /evsz r UtF \€ t^J sf Er, 4. Was this your usual work localion? Zf.. D No lf no, why were you atthis loca{lon? . . . 5. What wote you doing when you were injured or became iil? (e.g. , unloading a kuck, ..".... c/,{_r r feB { 6. How did the injurylillness happen? (e.g., I tripp€d over a pipe and fell on the lloor) fu"/arm^/k"fu,{ , *pYf c.rft. brXArt //r*"fl*{* ",?fr:?.tu/e? .*dfue hu u, /tr;Arri"t + T. Explain lully the nature of your injuryiillnes$i list body parts affected (e.g,, lwisted left ankle .. and cut to icrehearJ). . ilm& f?n