Preview
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 01/10/2021
DENIAL OF CLAIM FORM
TO INSURER: Complete this form, including item 33. Send 2 copiesto applicant. Upon the requestof the injured person, the insurer should sendto the injured person
a copy of all prescribedclaim forms and documentssubmitted by or on behalf of the injured person.
NAME, ADDRESSAND NAIC NUMBEROFINSURERORNAMEAND ADDRESSOFSELF-INSURER
HEREFORDINSURANCECOMPANY
36-0143 AVENUE2 FLOOR For AmericanArbitration AssociationUse
LONGISLAND CITY, NY 11101
NAIC: 2mo0
A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON
Intertransportation Auto Lyse Corp CA284924 06/28/2019 Kelvin Brioso
E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and Address) G. AS ASSIGNEE
86133-02 Kelvin Brioso (2) YES O NO 2
321 East Tremont Avenue Bronx, NY 10466
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL
YOU ARE ADVISED THAT FOR REASONS NOTED BELOW:
2 1. Your entire claim is denied asfollows:
O 2. A portion ofyour claim is denied asfollows:
O A. Loss of Earnings $ O D. Interest $
O B. Health ServiceBenefits $ O E. Attorney's Fee $
O C. Other NecessaryExpenses $ O F. Death Benefit $
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 33)
POLICY ISSUES
3. Person"
O Policy not in force on date of accident O 6. Injured personnot an "Eligible Injured
O 4. Injured person excluded under policy conditions or exclusion O 7. Injuries did not ariseout of use or operation of a motor vehicle
2 5. Policy conditions violated O 8. Claim not within the scopeofyour election under Optional
O a.No reasonablejustification given for late notice of claim Basic Economic Loss coverage
O b. Reasonablejustification not established- You may qualify
for special expedited arbitration - Seepage2 of this form for instructions.
LOSS OF EARNINGS BENEFITS DENIED
O 9. Period of disability contested:period in dispute O 11. Exaggeratedearningsclaim of $
From Through per month denied
O 10. Claimed loss not proven O 12. Statutory offset taken
2 13. Other, explained below
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
O 14. Amount of claim exceedsdaily limit of coverage O 16. Incurred after oneyear from date of accident
O 15. Unreasonableor unnecessaryexpenses 2 17. Other, explained below
HEALTH SERVICE BENEFITS DENIED
O 18. Feesnot in accordancewith fee schedules O 20. Treatment not related to accident
O 19. Excessive treatment, service or hospitalization O 21. Unnecessarytreatment, service or hospitalization
From Through From Through
2 22. Other, explained below
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED
23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill-treatment dates 29. Date final verification received
26. Date of bill 30.Amount of bill $
$
24. Type of servicerendered 27. Date bill received by insurer 31. Amount paid by insurer
$
No Fault Benefits
28. Date final verification requested 32. Amount in dispute
$
33. Statereasonfor denial, fully and explicitly (attach extra sheetsif needed):
"All No Fault benefits for the absic-injured personhave been denied effective 06/28/2019. The injured personfailed to appearfor E-W under oath on 11/12/2019
and 12/02/2019. The eligible injured personfailed to appearfor an examination under oath asreasonably requestedand scheduled. Thus, said assignorhas breacheda
vitiated"
policy condition to no fault benefits and entitlement to suchbenefits are thereby
cc: Pleaseseeattachedpage.
12/05/2019 Avril Piggott Sr. No Fault Adjuster 718-361-1221 X 7385
DATE Name and Title of Representative of Insurer Telephone No. & Ext.
Name and address of Insurer claim processor (Third Party Administrator), if applicable Telephone No. & Ext.
NYS FORMNF-10 (Rev 1/2013)
Page2 of 5
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 - PAGE
RECEIVED NYSCEF: 01/10/2021
DENIAL OF CLAIM FORM TWO
IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS:
1. Shouldyou wish to take this matter up with the New York StateDepãitent of Financial Services,you may file with the Depaiment either on its website at
www.dfs.ny.gov/consumer/fileacemplaint htm or you may write to or visit the Consumer Assistance Unit, Financial Frauds and Consumer Protection Division, New York
State Department of Financial Services, at: One State Street, New York, NY 10004; One Commerce Plaza, Albany, NY 12257; 1399 Franklin Avenue, Garden City, NY
11530, or Walter J. Mahoney Office Building, 65 Court Street, Buffalo, NY 14202.
Although the Department of Financial Serviceswill attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed claim. Ifyou wish to file a
written complaint, sendone copy of this Denial of Claim Form with copies of other pertinent documentswith a letter fully explaining your complaint to the Department of
Financial Services at one of the above addresses.
Ifyou choosethis option, you may at a later date still submit this disputeto arbitration or bring a lawsuit; or
2. You may submit this dispute to arbitration. Ifyou wish to submit this claim to arbitration, then mail or e-mail a copy of this Denial of Claim Form along with a
complete submission of all other pertinent documentsand a table of contents listing your mbmi=iens, in duplicate together with a $40 filing fee, payable by check, money
order, or credit card to the American Arbitration Association (AAA) to:
AMERICAN ARBITRATION ASSOCIATION (AAA)
NEW YORK INSURANCE CASE MANAGEMENT CENTER
120 BROADWAY
NEW YORK, NEW YORK 10006
nyiemc.Iningmbmissions@adr.org
Pleasecontactthe American Arbitration Association's customerservice departmentat (917) 438-1660 with any questionsabout casefiling.
A complete copy of this filing, listing all bills andproofs aswell asa table of contents listing your submi ion: must be provided to the AAA andthe insurer at the time of
filing for arbitration. The filing must be complete with all necessarydornrnentation, as any late submission may not be admissible at arbitration. The filing fee will be
returned to you if the arbitrator awardsyou any portion of your claim. However, you may be assessedthe costs of the arbitration proceeding if the arbitrator finds your
claim to be frivolous, without factual or legal merit or was filed for the purpose of harassing the respondent. The decision of an arbitrator is binding, except for limited
grounds for review set forth in the Law and regulations promulgated thereunder.
Ifyou are contesting the denial of claim andwish to submit the disputeto arbitration, stateon accompanying sheetsthe reason(s)you believe the denied or overduebenefits
should be paid. Attach proof of disability andverification of loss of eamings in dispute, sign below, and sendthe completedform to the American Arbitration Association at
the addressgiven in item 2 above.
Loss Of Earnings : Date claim made : GrossEarnings per month :$
Period of dispute : From : Through : Amount Claimed: $
Health Services: (Attach bills in dispute and list eachone separately)
Name of Providers Date of Service Amount of Bill Amount in Dispute Date Claim Mailed
Other NecessaryExpenses:(Attach bills in dispute and list eachone separately)
Type of ExpensesClaimed ] Amount Claimed Date Incurred Date Claim Mailed Amount in Dispute
Other: (attach additional sheetif necessary)
" Upon your re uest, ifyou file for arbitzntion within 90 days of the date of this denial or the claim becoming overdue,your casewill be scheduledfor arbitration on
a priority b
" You qualify for special expedited arbitration if the insurer has det-ined that your written justification for submitEng late notice of claim failed to meet a
"reasonablenes:standard".Your specific requestfor special expeditedarbitration must be filed within 30 days of the date of denial. Your filing must be complete
and contain all infe-nation that you are:ubmitting at the time offiling.
NYS FORMNF-10 (Rev 1/2013)
Page3 of 5
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
DENIAL OF CLAIM FORM - PAGE THREE
3. You may bring a lawsuit to recover the amount of benefits you claim to be entitled to.
THE UNDERSIGNED AFFIRMS AND CERTIFIES AS TRUE UNDER THE PENALTY OF PERJURY THAT THIS FILING IS BEl-NG MADE IN GOOD FAITH AND
THAT UPON INFORMATION, BELIEF AND REASONABLE INQUIRY THE DOCUMENTS BEING SUBMITTED HEREWITH ARE NOT FRAUDULENT AND
THAT EXACT COPIES OF ALL DOCUMENTS PROVIDED HEREWITH HAVE BEEN MAILED TO THE INSURER AGAINST WHOM THE ARBITRATION IS
BEING REQUESTED. UNLESS DISCLOSED WITH THIS SUBMISSION, THE DISPUTED AMOUNTS REMAIN UNPAID TO THE APPLICANT BY ANY PAYOR
AND THERE HAS BEENNO OTHER FILING OF AN ARBITRATION REQUEST OR LAWSUIT TO RESOLVE THE DISPUTED MATTERS CONTAINED IN THIS
SUBMISSION.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION
FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING
ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR
KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THE FT, DESTRUCTION,
DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN
INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL
PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH
VIOLATION.
ARBITRATION REQUESTED BY:
LAST NAME FIRST NAME NAME OF TAW FIRM. TFANY
TELEPHONE NUMBER:
FAX NUMBER:
E-MAIL ADDRESS: ADDRESS
ARE YOU AN ATTORNEY? DATE
SIGNATURE YES
NO O
IMPORTANT NOTICE TO APPLICANT
If box number 3 ("Policy not in force on date of accident") on the front of this form is checkedas a reasonfor this denial,y ou may be entitled to No-Fault benefits from the
Motor Vehicle Accident Indemnification Cemergen (M.V.A.I.C.) (646-205-7800) located at 100William Street,New York, New York 10038.The InsuranceLaw requires
that you must file an Affidavit of Intention to Make Claim with M.V.A.I.C. Therefore, it is in your best interest to contact the M.V.A.I.C. immediately and file such an
affidavit, even if you intend to contestthis denial.
NYS FORMNF-10 (Rev 1/2013)
Page4 of 5
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
Cc:
Co : Stephen'sAcupuncture PC
2266 Bath Avenue #089, Brooklyn, NY 11214
Co : JosephA Rossello DC
PO BOX 307 , Pararnus,NJ 07653
Co : Perloff Physical Therapy PC
2896 Shell Rd #73, Brookyln, NY 11224
Co : Arthur Avenue Medical Office PC
2309 Arthur Avenue , Bronx, NY 10458
Co : Nile Rehab FT PC
PO BOX 87 , Brooklyn, NY 11214
Co : Fairpoint Acupuncture PC
2896 Shell Road #69, Brooklyn, NY 11224
Co : Future Chiropractic CarePC
2995 Ocean Pkwy 1st Floor, BrookyIn, NY 11235
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NYS FORM NF-10 (Rev 1/2013)
Page5 of 5
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
LAW OFFICES OF
RUBIN & NAZARIAN
Attorneys at Law
43rd
36-o1 Avenue
Long Island City, NY 11101
Telephone (347) 418-3830
Staff Counsel
Not a Partnership or Professional Corporation
October 24, 2019
Via Regular and Certified Mail, Return Receipt Reauested
Kelvin Brioso
321 East Tremont Ave Apt 206
Bronx, NY 10466
Re: EXAMINATION UNDER OATH OF KELVIN BRIOSO
Legal #: E-86133
Claim #: 86133-02
Date of Loss: 6/28/19
Dear Mr. Brioso:
In accordance with the above-mentioned insurance with Hereford Insurance Company,
policy
you are required to attend an Examination Under Oath (EUO) to be held at Diamond Reporting
located at: 880 River Avenue, Lower Level, Bronx, NY 10452 on: November 12th, 2019 at 10:00
AM which will serve as additional verification of the related claim and will allow Hereford the
to inquire about the facts of the alleged accident, any related medical
opportunity including
treatment which have been administered as a result of the accident. If medical
may any
supplies were issued, please them with you to the EUO.
bring
Although it is not required, it may be advisable to have counsel present at the EUO.
As required under Regulation 68, all reasonable transportation expenses and any lost wages will
be reimbursed within a reasonable period. Please provide all relevant travel receipts and/or
documentation of related lost earnings.
any
Please be advised that this letter, Hereford Insurance does not ad,nut
by issuing Company
under said policy, nor does it waive rights or defenses that it possess.
liability any may
Failure to keep the scheduled appointment will be interpreted as a lack of cooperation oby
Hereford as required under your policy, resulting
in loss of all benefits, even for inju,ries
whose symptoms have yet to materiahze.
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
You must call this office by 3:00 p.m. on the last business day immediately preceding the
examination date to confirm your appearance.
Should you be unable to appear on the above scheduled date or require an interpreter, please
contact Raynier Peralta at (347) 418-3830 at least 48 hours prior to the EUO and he will attempt
to reschedule it at a more convenient date and time and will retain an interpreter (if necessar )
Thank you in advance for your cooperation.
Sincerely,
Rubin & Nazarian
Attorneys for Hereford Insurance Company
Raynier Peralta
EUO Clerk .
2
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
ShipRequest"
Ship To: Kelvin Brioso
Company:
Address 1: 321 East Tremont Ave Apt 206
Address 2:
Address 3:
City: Bronx
State/Province: New York
ZIP/Postal Code: 10466
Country: United States
email :
Phone:
Account: 610
Package Type: Package
Address Type: Commercial
Deliver By: Mon, October 28, 2019
Special Instructions:
9414 8149 0101 3026 2573 15
Sender Name: Raynier Peralta
email : rperalta@heref ordinsurance. com
Prepared By:
Phone: File # E-8 6133
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
PO5TAL SEt?VICE
November 19, 2019
Dear Raynier Peralta:
The following is in response to your request for proof of delivery on your item with the tracking number:
9414 8149 0101 3026 2573 08
Itern Details
Status: Delivered, Front Desk/Reception/Mail Room
Status Date / Time: October 28, 2019, 3:28 pm
Location: NEW YORK, NY 10018
Mail®
Postal Product: First-Class
Extra Services: Certified Mail™
Return Receipt Electronic
Recipisñt Name: Adam D Polo Esq P C
Shipment Details
Weight: 0.2oz
Recipient S gnature
Signature of Recipient:
Address of Recipient:
Note: Scanned image may reflect a different destination address due to latended Recipient's deHvery instructions on file.
Service"
Thank you for selecting the United States Postal for your mailing needs. If you require additional
assistance, please contact your local Post Office™ or a Postal representative at 1-800-222-1811.
Sincerely,
Service®
United States Postal
475 L'Enfant Plaza SW
Washington, D.C. 20260-0004
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
LAW OFFICES OF
RUBIN & NAZARIAN
Attorneys at Law
43'·d
36-01 Avenue
Long Island City, NY 11101
Telephone (347) 418-3830
Fax (347) 418-3838
Staff Counsel
Not a Partnership or Professional Corporation
November 13, 2019
Via Regular and Certified Mail Return Receipt Requested
Kelvin Brioso
321 East Tremont Ave Apt 206
Bronx NY 10466
Re: EXAMINATION UNDER OATH OF KELVIN BRIOSO
Insured: Intertransportation Auto Lyse Corp
Legal #: E-86133
Claim #: 86133-02
Date of Loss: 6 /28/19
Dear Mr. Brioso:
This letter is to confirm that the Examination Under Oath currently scheduled for 11/12/19 has
been adjourned. Even though you appeared, the EUO was never held which will count as a No Show
since we couldn't confirm anywhere that you had representation and will be rescheduled as follows:
Date: 12 / 2 /19
Time: 10:00AM
Location: Diamond Reporting, 880 River Avenue, Lower Level Bronx NY 10452
As required under Regulation 68, all reasonable transportation expenses and any
lost wages will be reimbursed within a reasonable period. Please provide all relevant
travel receipts and/or documentation of related lost earnings.
any
Please be advised that this letter, Hereford Insurance Company does not
by issuing
admit under said policy, nor does it waive rights or defenses that it
liability any may
possess.
Failure to the scheduled appointment will be interpreted as a lack of cooperation
keep
by Hereford as required under your policy, resulting in loss of all benefits, even for
injuries whose symptoms have yet to materialize.
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
Please mark your calendar accordingly. Kindly call this office before 3:00 p.m. on the last
business day immediately preceding the examination date the appearance
Thank you for your attention to this matter.
Very truly yours,
LAW OFFIC 7F RUBIN & NAZARIAN
By: Raynier Peralta
Paralegal
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
i Pitney Bowes
ShipRequest"
Ship To: Kelvin Brioso
Company:
Address 1: 321 East Tremont Ave Apt 206
Address 2:
Address 3:
City: Bronx
State/Province: New York
ZIP/Postal Code: 10466
Country: United States
email:
Phone:
Account: 610
Package Type: Package
Address Type: Commercial
Deliver By: Sat, November 16, 2019
________...........
Special Instructions:
f 9414 8149 0101 3026 2605 68
Sender Name: Raynier Peralta
email: rperalta@herefordinsurance.com
Prepared By:
Phone: File # E-86133
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
December 4,.2019
Dear Raynier Peralta:
The following is in response to your request for proof of delivery on your item with the tracking number:
9414 8149 0101 3026 2605 68.
item Details
Status: Delivered, Left with Individual
Status Date / Time: November 15, 2019, 10:59 am
Location: BRONX, NY 10457
Mail®
Postal Product: First-Class
Extra Services: Certified Mail™
Retum Receipt Electronic
Recipient Name: Kelvin Brioso
Shipment Details
Weight: 0.2oz
Recipient Signature
Signature of Recipient:
Address of Recipient:
Note: Scanned image may reflect a different destinaÈon address due to intended Recipient's del e instructions on file.
Service®
Thank you for selecting the United States Postal for your mailing needs. If you require -dditiõñal
assistance, please contact your local Post Office™ or a Postal representative at 1-800-222-1811.
Sincerely,
Service®
United States Postal
475 L'Enfant Plaza SW
Washington, D.C. 20260-0004
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021
LAW OFFICES OF
RUBIN & NAZARLAN
Attorneys at Law
43rd
36-01 Avenue
Long Island City, NY 11101
Telephone (347) 418-3830
Fax (347) 418-3838
Staff Counsel
Not a Partnership or Professional Corporation
November 13, 2019
Via Regular and Cerdfied Mail Return Receipt Requested
Kelvin Brioso
321 East Tremont Ave Apt 206
Bronx NY 10466
Re: EXAMINATION UNDER OATH OF KELVIN BRIOSO
Insured: Intertransportation Auto Lyse Corp
Legal #: E-86133
Claim #: 86133-02
Date of Loss: 6/28/19
Dear Mr. Brioso:
This letter is to confirm that the Examination Under Oath currently scheduled for 11/12/19 has
been adjourned. Even though you appeared, the EUO was never held which will count as a No Show
since we couldn't confirm anywhere that you had representation and will be rescheduled as follows:
Date: 12/2/19
Time: 10:00AM
Location: Diamond Reporting, 880 River Avenue, Lower Level Bronx NY 10452
As required under Regulation 68, all reasonable transportation expenses and any
lost wages will be reimbursed within a reasonable period. Please provide all relevant
travel receipts and/or documentation of any related lost earnings.
Please be advised that this letter, Hereford Insurance Company does not
by issuing
admit under said policy, nor does it waive rights or defenses that it
liability any may
possess.
Failure to keep the scheduled appointment will be interpreted as a lack of cooperation
by Hereford as required under your policy, re
Preview
FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 01/10/2021 DENIAL OF CLAIM FORM TO INSURER: Complete this form, including item 33. Send 2 copiesto applicant. Upon the requestof the injured person, the insurer should sendto the injured person a copy of all prescribedclaim forms and documentssubmitted by or on behalf of the injured person. NAME, ADDRESSAND NAIC NUMBEROFINSURERORNAMEAND ADDRESSOFSELF-INSURER HEREFORDINSURANCECOMPANY 36-0143 AVENUE2 FLOOR For AmericanArbitration AssociationUse LONGISLAND CITY, NY 11101 NAIC: 2mo0 A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON Intertransportation Auto Lyse Corp CA284924 06/28/2019 Kelvin Brioso E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and Address) G. AS ASSIGNEE 86133-02 Kelvin Brioso (2) YES O NO 2 321 East Tremont Avenue Bronx, NY 10466 TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL YOU ARE ADVISED THAT FOR REASONS NOTED BELOW: 2 1. Your entire claim is denied asfollows: O 2. A portion ofyour claim is denied asfollows: O A. Loss of Earnings $ O D. Interest $ O B. Health ServiceBenefits $ O E. Attorney's Fee $ O C. Other NecessaryExpenses $ O F. Death Benefit $ REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 33) POLICY ISSUES 3. Person" O Policy not in force on date of accident O 6. Injured personnot an "Eligible Injured O 4. Injured person excluded under policy conditions or exclusion O 7. Injuries did not ariseout of use or operation of a motor vehicle 2 5. Policy conditions violated O 8. Claim not within the scopeofyour election under Optional O a.No reasonablejustification given for late notice of claim Basic Economic Loss coverage O b. Reasonablejustification not established- You may qualify for special expedited arbitration - Seepage2 of this form for instructions. LOSS OF EARNINGS BENEFITS DENIED O 9. Period of disability contested:period in dispute O 11. Exaggeratedearningsclaim of $ From Through per month denied O 10. Claimed loss not proven O 12. Statutory offset taken 2 13. Other, explained below OTHER REASONABLE AND NECESSARY EXPENSES DENIED O 14. Amount of claim exceedsdaily limit of coverage O 16. Incurred after oneyear from date of accident O 15. Unreasonableor unnecessaryexpenses 2 17. Other, explained below HEALTH SERVICE BENEFITS DENIED O 18. Feesnot in accordancewith fee schedules O 20. Treatment not related to accident O 19. Excessive treatment, service or hospitalization O 21. Unnecessarytreatment, service or hospitalization From Through From Through 2 22. Other, explained below COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED 23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill-treatment dates 29. Date final verification received 26. Date of bill 30.Amount of bill $ $ 24. Type of servicerendered 27. Date bill received by insurer 31. Amount paid by insurer $ No Fault Benefits 28. Date final verification requested 32. Amount in dispute $ 33. Statereasonfor denial, fully and explicitly (attach extra sheetsif needed): "All No Fault benefits for the absic-injured personhave been denied effective 06/28/2019. The injured personfailed to appearfor E-W under oath on 11/12/2019 and 12/02/2019. The eligible injured personfailed to appearfor an examination under oath asreasonably requestedand scheduled. Thus, said assignorhas breacheda vitiated" policy condition to no fault benefits and entitlement to suchbenefits are thereby cc: Pleaseseeattachedpage. 12/05/2019 Avril Piggott Sr. No Fault Adjuster 718-361-1221 X 7385 DATE Name and Title of Representative of Insurer Telephone No. & Ext. Name and address of Insurer claim processor (Third Party Administrator), if applicable Telephone No. & Ext. NYS FORMNF-10 (Rev 1/2013) Page2 of 5 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 - PAGE RECEIVED NYSCEF: 01/10/2021 DENIAL OF CLAIM FORM TWO IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS: 1. Shouldyou wish to take this matter up with the New York StateDepãitent of Financial Services,you may file with the Depaiment either on its website at www.dfs.ny.gov/consumer/fileacemplaint htm or you may write to or visit the Consumer Assistance Unit, Financial Frauds and Consumer Protection Division, New York State Department of Financial Services, at: One State Street, New York, NY 10004; One Commerce Plaza, Albany, NY 12257; 1399 Franklin Avenue, Garden City, NY 11530, or Walter J. Mahoney Office Building, 65 Court Street, Buffalo, NY 14202. Although the Department of Financial Serviceswill attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed claim. Ifyou wish to file a written complaint, sendone copy of this Denial of Claim Form with copies of other pertinent documentswith a letter fully explaining your complaint to the Department of Financial Services at one of the above addresses. Ifyou choosethis option, you may at a later date still submit this disputeto arbitration or bring a lawsuit; or 2. You may submit this dispute to arbitration. Ifyou wish to submit this claim to arbitration, then mail or e-mail a copy of this Denial of Claim Form along with a complete submission of all other pertinent documentsand a table of contents listing your mbmi=iens, in duplicate together with a $40 filing fee, payable by check, money order, or credit card to the American Arbitration Association (AAA) to: AMERICAN ARBITRATION ASSOCIATION (AAA) NEW YORK INSURANCE CASE MANAGEMENT CENTER 120 BROADWAY NEW YORK, NEW YORK 10006 nyiemc.Iningmbmissions@adr.org Pleasecontactthe American Arbitration Association's customerservice departmentat (917) 438-1660 with any questionsabout casefiling. A complete copy of this filing, listing all bills andproofs aswell asa table of contents listing your submi ion: must be provided to the AAA andthe insurer at the time of filing for arbitration. The filing must be complete with all necessarydornrnentation, as any late submission may not be admissible at arbitration. The filing fee will be returned to you if the arbitrator awardsyou any portion of your claim. However, you may be assessedthe costs of the arbitration proceeding if the arbitrator finds your claim to be frivolous, without factual or legal merit or was filed for the purpose of harassing the respondent. The decision of an arbitrator is binding, except for limited grounds for review set forth in the Law and regulations promulgated thereunder. Ifyou are contesting the denial of claim andwish to submit the disputeto arbitration, stateon accompanying sheetsthe reason(s)you believe the denied or overduebenefits should be paid. Attach proof of disability andverification of loss of eamings in dispute, sign below, and sendthe completedform to the American Arbitration Association at the addressgiven in item 2 above. Loss Of Earnings : Date claim made : GrossEarnings per month :$ Period of dispute : From : Through : Amount Claimed: $ Health Services: (Attach bills in dispute and list eachone separately) Name of Providers Date of Service Amount of Bill Amount in Dispute Date Claim Mailed Other NecessaryExpenses:(Attach bills in dispute and list eachone separately) Type of ExpensesClaimed ] Amount Claimed Date Incurred Date Claim Mailed Amount in Dispute Other: (attach additional sheetif necessary) " Upon your re uest, ifyou file for arbitzntion within 90 days of the date of this denial or the claim becoming overdue,your casewill be scheduledfor arbitration on a priority b " You qualify for special expedited arbitration if the insurer has det-ined that your written justification for submitEng late notice of claim failed to meet a "reasonablenes:standard".Your specific requestfor special expeditedarbitration must be filed within 30 days of the date of denial. Your filing must be complete and contain all infe-nation that you are:ubmitting at the time offiling. NYS FORMNF-10 (Rev 1/2013) Page3 of 5 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 DENIAL OF CLAIM FORM - PAGE THREE 3. You may bring a lawsuit to recover the amount of benefits you claim to be entitled to. THE UNDERSIGNED AFFIRMS AND CERTIFIES AS TRUE UNDER THE PENALTY OF PERJURY THAT THIS FILING IS BEl-NG MADE IN GOOD FAITH AND THAT UPON INFORMATION, BELIEF AND REASONABLE INQUIRY THE DOCUMENTS BEING SUBMITTED HEREWITH ARE NOT FRAUDULENT AND THAT EXACT COPIES OF ALL DOCUMENTS PROVIDED HEREWITH HAVE BEEN MAILED TO THE INSURER AGAINST WHOM THE ARBITRATION IS BEING REQUESTED. UNLESS DISCLOSED WITH THIS SUBMISSION, THE DISPUTED AMOUNTS REMAIN UNPAID TO THE APPLICANT BY ANY PAYOR AND THERE HAS BEENNO OTHER FILING OF AN ARBITRATION REQUEST OR LAWSUIT TO RESOLVE THE DISPUTED MATTERS CONTAINED IN THIS SUBMISSION. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THE FT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION. ARBITRATION REQUESTED BY: LAST NAME FIRST NAME NAME OF TAW FIRM. TFANY TELEPHONE NUMBER: FAX NUMBER: E-MAIL ADDRESS: ADDRESS ARE YOU AN ATTORNEY? DATE SIGNATURE YES NO O IMPORTANT NOTICE TO APPLICANT If box number 3 ("Policy not in force on date of accident") on the front of this form is checkedas a reasonfor this denial,y ou may be entitled to No-Fault benefits from the Motor Vehicle Accident Indemnification Cemergen (M.V.A.I.C.) (646-205-7800) located at 100William Street,New York, New York 10038.The InsuranceLaw requires that you must file an Affidavit of Intention to Make Claim with M.V.A.I.C. Therefore, it is in your best interest to contact the M.V.A.I.C. immediately and file such an affidavit, even if you intend to contestthis denial. NYS FORMNF-10 (Rev 1/2013) Page4 of 5 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 Cc: Co : Stephen'sAcupuncture PC 2266 Bath Avenue #089, Brooklyn, NY 11214 Co : JosephA Rossello DC PO BOX 307 , Pararnus,NJ 07653 Co : Perloff Physical Therapy PC 2896 Shell Rd #73, Brookyln, NY 11224 Co : Arthur Avenue Medical Office PC 2309 Arthur Avenue , Bronx, NY 10458 Co : Nile Rehab FT PC PO BOX 87 , Brooklyn, NY 11214 Co : Fairpoint Acupuncture PC 2896 Shell Road #69, Brooklyn, NY 11224 Co : Future Chiropractic CarePC 2995 Ocean Pkwy 1st Floor, BrookyIn, NY 11235 Co : Metro Medical & Surgical 2076 East 13th Street , Brooklyn, NY 11229 Co : Rapid Imaging Corp PO BOX 245034 , Brookyln, NY 11224 Co : Arte Medical Primary CarePC 129 Livingston Street 3RD FLO OR, BrookyIn, NY 11201 Co : AZ CARE 1NC PO BOX 290698 , Brooklyn, NY 11229 NYS FORM NF-10 (Rev 1/2013) Page5 of 5 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 LAW OFFICES OF RUBIN & NAZARIAN Attorneys at Law 43rd 36-o1 Avenue Long Island City, NY 11101 Telephone (347) 418-3830 Staff Counsel Not a Partnership or Professional Corporation October 24, 2019 Via Regular and Certified Mail, Return Receipt Reauested Kelvin Brioso 321 East Tremont Ave Apt 206 Bronx, NY 10466 Re: EXAMINATION UNDER OATH OF KELVIN BRIOSO Legal #: E-86133 Claim #: 86133-02 Date of Loss: 6/28/19 Dear Mr. Brioso: In accordance with the above-mentioned insurance with Hereford Insurance Company, policy you are required to attend an Examination Under Oath (EUO) to be held at Diamond Reporting located at: 880 River Avenue, Lower Level, Bronx, NY 10452 on: November 12th, 2019 at 10:00 AM which will serve as additional verification of the related claim and will allow Hereford the to inquire about the facts of the alleged accident, any related medical opportunity including treatment which have been administered as a result of the accident. If medical may any supplies were issued, please them with you to the EUO. bring Although it is not required, it may be advisable to have counsel present at the EUO. As required under Regulation 68, all reasonable transportation expenses and any lost wages will be reimbursed within a reasonable period. Please provide all relevant travel receipts and/or documentation of related lost earnings. any Please be advised that this letter, Hereford Insurance does not ad,nut by issuing Company under said policy, nor does it waive rights or defenses that it possess. liability any may Failure to keep the scheduled appointment will be interpreted as a lack of cooperation oby Hereford as required under your policy, resulting in loss of all benefits, even for inju,ries whose symptoms have yet to materiahze. FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 You must call this office by 3:00 p.m. on the last business day immediately preceding the examination date to confirm your appearance. Should you be unable to appear on the above scheduled date or require an interpreter, please contact Raynier Peralta at (347) 418-3830 at least 48 hours prior to the EUO and he will attempt to reschedule it at a more convenient date and time and will retain an interpreter (if necessar ) Thank you in advance for your cooperation. Sincerely, Rubin & Nazarian Attorneys for Hereford Insurance Company Raynier Peralta EUO Clerk . 2 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 ShipRequest" Ship To: Kelvin Brioso Company: Address 1: 321 East Tremont Ave Apt 206 Address 2: Address 3: City: Bronx State/Province: New York ZIP/Postal Code: 10466 Country: United States email : Phone: Account: 610 Package Type: Package Address Type: Commercial Deliver By: Mon, October 28, 2019 Special Instructions: 9414 8149 0101 3026 2573 15 Sender Name: Raynier Peralta email : rperalta@heref ordinsurance. com Prepared By: Phone: File # E-8 6133 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 PO5TAL SEt?VICE November 19, 2019 Dear Raynier Peralta: The following is in response to your request for proof of delivery on your item with the tracking number: 9414 8149 0101 3026 2573 08 Itern Details Status: Delivered, Front Desk/Reception/Mail Room Status Date / Time: October 28, 2019, 3:28 pm Location: NEW YORK, NY 10018 Mail® Postal Product: First-Class Extra Services: Certified Mail™ Return Receipt Electronic Recipisñt Name: Adam D Polo Esq P C Shipment Details Weight: 0.2oz Recipient S gnature Signature of Recipient: Address of Recipient: Note: Scanned image may reflect a different destination address due to latended Recipient's deHvery instructions on file. Service" Thank you for selecting the United States Postal for your mailing needs. If you require additional assistance, please contact your local Post Office™ or a Postal representative at 1-800-222-1811. Sincerely, Service® United States Postal 475 L'Enfant Plaza SW Washington, D.C. 20260-0004 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 LAW OFFICES OF RUBIN & NAZARIAN Attorneys at Law 43'·d 36-01 Avenue Long Island City, NY 11101 Telephone (347) 418-3830 Fax (347) 418-3838 Staff Counsel Not a Partnership or Professional Corporation November 13, 2019 Via Regular and Certified Mail Return Receipt Requested Kelvin Brioso 321 East Tremont Ave Apt 206 Bronx NY 10466 Re: EXAMINATION UNDER OATH OF KELVIN BRIOSO Insured: Intertransportation Auto Lyse Corp Legal #: E-86133 Claim #: 86133-02 Date of Loss: 6 /28/19 Dear Mr. Brioso: This letter is to confirm that the Examination Under Oath currently scheduled for 11/12/19 has been adjourned. Even though you appeared, the EUO was never held which will count as a No Show since we couldn't confirm anywhere that you had representation and will be rescheduled as follows: Date: 12 / 2 /19 Time: 10:00AM Location: Diamond Reporting, 880 River Avenue, Lower Level Bronx NY 10452 As required under Regulation 68, all reasonable transportation expenses and any lost wages will be reimbursed within a reasonable period. Please provide all relevant travel receipts and/or documentation of related lost earnings. any Please be advised that this letter, Hereford Insurance Company does not by issuing admit under said policy, nor does it waive rights or defenses that it liability any may possess. Failure to the scheduled appointment will be interpreted as a lack of cooperation keep by Hereford as required under your policy, resulting in loss of all benefits, even for injuries whose symptoms have yet to materialize. FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 Please mark your calendar accordingly. Kindly call this office before 3:00 p.m. on the last business day immediately preceding the examination date the appearance Thank you for your attention to this matter. Very truly yours, LAW OFFIC 7F RUBIN & NAZARIAN By: Raynier Peralta Paralegal FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 i Pitney Bowes ShipRequest" Ship To: Kelvin Brioso Company: Address 1: 321 East Tremont Ave Apt 206 Address 2: Address 3: City: Bronx State/Province: New York ZIP/Postal Code: 10466 Country: United States email: Phone: Account: 610 Package Type: Package Address Type: Commercial Deliver By: Sat, November 16, 2019 ________........... Special Instructions: f 9414 8149 0101 3026 2605 68 Sender Name: Raynier Peralta email: rperalta@herefordinsurance.com Prepared By: Phone: File # E-86133 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 December 4,.2019 Dear Raynier Peralta: The following is in response to your request for proof of delivery on your item with the tracking number: 9414 8149 0101 3026 2605 68. item Details Status: Delivered, Left with Individual Status Date / Time: November 15, 2019, 10:59 am Location: BRONX, NY 10457 Mail® Postal Product: First-Class Extra Services: Certified Mail™ Retum Receipt Electronic Recipient Name: Kelvin Brioso Shipment Details Weight: 0.2oz Recipient Signature Signature of Recipient: Address of Recipient: Note: Scanned image may reflect a different destinaÈon address due to intended Recipient's del e instructions on file. Service® Thank you for selecting the United States Postal for your mailing needs. If you require -dditiõñal assistance, please contact your local Post Office™ or a Postal representative at 1-800-222-1811. Sincerely, Service® United States Postal 475 L'Enfant Plaza SW Washington, D.C. 20260-0004 FILED: NEW YORK COUNTY CLERK 01/10/2021 06:44 PM INDEX NO. 651472/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 01/10/2021 LAW OFFICES OF RUBIN & NAZARLAN Attorneys at Law 43rd 36-01 Avenue Long Island City, NY 11101 Telephone (347) 418-3830 Fax (347) 418-3838 Staff Counsel Not a Partnership or Professional Corporation November 13, 2019 Via Regular and Cerdfied Mail Return Receipt Requested Kelvin Brioso 321 East Tremont Ave Apt 206 Bronx NY 10466 Re: EXAMINATION UNDER OATH OF KELVIN BRIOSO Insured: Intertransportation Auto Lyse Corp Legal #: E-86133 Claim #: 86133-02 Date of Loss: 6/28/19 Dear Mr. Brioso: This letter is to confirm that the Examination Under Oath currently scheduled for 11/12/19 has been adjourned. Even though you appeared, the EUO was never held which will count as a No Show since we couldn't confirm anywhere that you had representation and will be rescheduled as follows: Date: 12/2/19 Time: 10:00AM Location: Diamond Reporting, 880 River Avenue, Lower Level Bronx NY 10452 As required under Regulation 68, all reasonable transportation expenses and any lost wages will be reimbursed within a reasonable period. Please provide all relevant travel receipts and/or documentation of any related lost earnings. Please be advised that this letter, Hereford Insurance Company does not by issuing admit under said policy, nor does it waive rights or defenses that it liability any may possess. Failure to keep the scheduled appointment will be interpreted as a lack of cooperation by Hereford as required under your policy, re