On August 26, 2021 a
EXHIBIT(S) - S (Motion #003) - PORTION OF WORKER'S COMPENSATION FILE
was filed
involving a dispute between
Silas Ajawuihe,
and
Carmen Mathe,
Jane Mathe
The First Name Being Fictitious,
Lawrence Mathe,
for Torts - Other (Dog Attack)
in the District Court of Richmond County.
Preview
FILED: RICHMOND COUNTY CLERK 04/06/2023 09:03 AM INDEX NO. 151617/2021
NYSCEF DOC. NO. 122 RECEIVED NYSCEF: 04/06/2023
"S"
EXHIBIT
FILED: RICHMOND COUNTY CLERK 04/06/2023 09:03 AM INDEX NO. 151617/2021
NYSCEF DOC. NO. 122 RECEIVED NYSCEF: 04/06/2023
Time of injury 21:00 Date Employer Had Knowledge of the 05/27/2021
injury
Employment Status 1 - Regular/Full-time Employee Date Claim Administrator Had Knowledge of the Injusy 05/28/2021
Wage Period 01 -Weekly Date Employer Had Knowledge of Date of Disability
Estimated Wage $200.00 Number of Days Worked Per Week 5
S M T W T F S
Work Week Type 5 - Standard Work Week Work Days Scheduled (S-Scheduled N-Non Scheduled) N 5 S 5 5 5 N
Date of Denial Rescission
EntPLOYEEINJURY
Full Wages Paid for Date of Injury Yes Employer Paid Salary in Lieu of Compensation No
Death Result of Injury Date of Death Number of Dependents
Nature of Injury 40 - Laceration
Part of Body 53 - Knee
Cause of Injury 85 - Struck or Injured By - Animal or Insect __
Type of Loss 01 - Traumatic
Injury
Accidentfinjury Description
EE WAS IN THE CUSTOMERS HOUSE WHEN SAW A DOG IN THE ENTRANCELACERATION TO KNEE
WORK STATUS
Initial Date Last Day Worked Return To Work Type
Initial Date Disability Began Physical Restrictions
Initial Return to Work Date Return To Work Same Employer
Premises E - Employer
Organization Name CHARTER COMMUNICATIOES
Street 405 GREELEY AVE State NY
City STATEN ISLAND Postal Code 10306
County/Parish RICHMOND - Richmond US - UNITED STATES
Country
Location Narrative
Witnesses Business Phone Number
FRol-00-R3 (1-14) Page 2 of 3 www.wch,ny-gov
FILED: RICHMOND COUNTY CLERK 04/06/2023 09:03 AM INDEX NO. 151617/2021
NYSCEF DOC. NO. 122 RECEIVED NYSCEF: 04/06/2023
Initial Treatment 2 - Minor Clinic/Hosp Remedies/Diagnostics
Managed Care Org.
Managed Care Org. ID
.. E PLOVERINFONMATION
. . .. .. .
Name CHARTER COMMUNICATIONS Employer FEIN xxxxx8755
industry Code 515210 UI Number
Manual Classification 7600 - Telephone Or Telegraph Co.-AN Other Employees-& Drivers
Info/Attn
Malling Address 100 CABLEWAY
City ST ATEN ISLAND State NY
Postal Code 10303
Country US - UNITED STATES
Physical Addr 100 CABLEWAY
City STATEN ISLAND State NY
Postal Code 10303
Country US - UNITED STATES
Contact Name AJAWUIHE;SILAS
Contact Business Phone Number 8629300037
. . .. . . . INSURED F#RMATION . .
Insured Name CHARTER COMMUNICATIONS Insured FEIN xxxxx6755
Insured Type I - Insured Insured Location ID
Policy Number ID WC014122399
Policy Effective Date 01/01/2021
Policy Expiration Date 12/31/2021
FROl-DO-R3 (1-14) Page 3 of 3 www.wch.ny.gov
Document Filed Date
April 06, 2023
Case Filing Date
August 26, 2021
Category
Torts - Other (Dog Attack)
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FILED: RICHMOND COUNTY CLERK 04/06/2023 09:03 AM INDEX NO. 151617/2021 NYSCEF DOC. NO. 122 RECEIVED NYSCEF: 04/06/2023 "S" EXHIBIT FILED: RICHMOND COUNTY CLERK 04/06/2023 09:03 AM INDEX NO. 151617/2021 NYSCEF DOC. NO. 122 RECEIVED NYSCEF: 04/06/2023 Time of injury 21:00 Date Employer Had Knowledge of the 05/27/2021 injury Employment Status 1 - Regular/Full-time Employee Date Claim Administrator Had Knowledge of the Injusy 05/28/2021 Wage Period 01 -Weekly Date Employer Had Knowledge of Date of Disability Estimated Wage $200.00 Number of Days Worked Per Week 5 S M T W T F S Work Week Type 5 - Standard Work Week Work Days Scheduled (S-Scheduled N-Non Scheduled) N 5 S 5 5 5 N Date of Denial Rescission EntPLOYEEINJURY Full Wages Paid for Date of Injury Yes Employer Paid Salary in Lieu of Compensation No Death Result of Injury Date of Death Number of Dependents Nature of Injury 40 - Laceration Part of Body 53 - Knee Cause of Injury 85 - Struck or Injured By - Animal or Insect __ Type of Loss 01 - Traumatic Injury Accidentfinjury Description EE WAS IN THE CUSTOMERS HOUSE WHEN SAW A DOG IN THE ENTRANCELACERATION TO KNEE WORK STATUS Initial Date Last Day Worked Return To Work Type Initial Date Disability Began Physical Restrictions Initial Return to Work Date Return To Work Same Employer Premises E - Employer Organization Name CHARTER COMMUNICATIOES Street 405 GREELEY AVE State NY City STATEN ISLAND Postal Code 10306 County/Parish RICHMOND - Richmond US - UNITED STATES Country Location Narrative Witnesses Business Phone Number FRol-00-R3 (1-14) Page 2 of 3 www.wch,ny-gov FILED: RICHMOND COUNTY CLERK 04/06/2023 09:03 AM INDEX NO. 151617/2021 NYSCEF DOC. NO. 122 RECEIVED NYSCEF: 04/06/2023 Initial Treatment 2 - Minor Clinic/Hosp Remedies/Diagnostics Managed Care Org. Managed Care Org. ID .. E PLOVERINFONMATION . . .. .. . Name CHARTER COMMUNICATIONS Employer FEIN xxxxx8755 industry Code 515210 UI Number Manual Classification 7600 - Telephone Or Telegraph Co.-AN Other Employees-& Drivers Info/Attn Malling Address 100 CABLEWAY City ST ATEN ISLAND State NY Postal Code 10303 Country US - UNITED STATES Physical Addr 100 CABLEWAY City STATEN ISLAND State NY Postal Code 10303 Country US - UNITED STATES Contact Name AJAWUIHE;SILAS Contact Business Phone Number 8629300037 . . .. . . . INSURED F#RMATION . . Insured Name CHARTER COMMUNICATIONS Insured FEIN xxxxx6755 Insured Type I - Insured Insured Location ID Policy Number ID WC014122399 Policy Effective Date 01/01/2021 Policy Expiration Date 12/31/2021 FROl-DO-R3 (1-14) Page 3 of 3 www.wch.ny.gov