Preview
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
Exhibit A
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
Workers' "²°
State of New York - Compensation Board
Subsequent Report of Injury
Report Type (MTC) SA-Sub-Annual
This paper contains information that has been provided electronically to the Bœrd. Do no_t serve a copy of this on the Board.
ErñpIrayee Name JOSEPH ITARA
WCB Case Number (JCN) G2577585 Date of Injury 08/13/2019
Claim Administrator Claim Number B9600F6339000101600 A'±±mnce Type Code Date 07/28/2021
WCB Received Date 07/28/2021
Agreement to Cc=parmate
IN$URER INFORMATloN
FEIN xxxxx0372 Insurer ID W183693
CLAIM ADMINISTRATOR INFORMATION
Name SEDGWICK CLAIMS MANAGEMENT SERVICES, INC FEIN xxxxx5608
Claim Rêpic::7.2tive Name AMANDA WATERS Postal Code 40512-4156
Business Phone Number 3154264998 Fax Number
E-mail Address AMANDA.WATERS@SEDGWICK.COM Claim Admin ID T100083
El I EOhi EE INi#ORM TION
First Name JOSEPH Middle Nc==!::itial
Last Name ITARA Suffix
Date of Birth 4
=mpicyee ID Type S - Employee Social Security Number Emp|Gyäs ID ××××x7713
BENERTS
Benefits
050 - Temporary Total
070 - Temporary Partial
Benefits - Cumulative
SROI-SA-R3 (1-14) Page 1 of 2 www.wcb.ny.gov
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
S9517120
Start Through Claim Claim Amount
Benefit ype
Date Date Weeks Days PaK‡
050 - Temporary Total 08/14/2019 01/03/2020 20 3 $19,242.67
070 - Temporary Partial 01/04/2020 07/16/2021 80 O $74,728.80
Benefits - A - Adjustments / C - Credits / R - Redistributions
Other Benefits
Other Beneñt Type Amount Other Benefit T ype Amount
340 - Total Claimant's Legal Expenses $1,600.00 350 - Total Payments to Physicians $7,770.49
360 - Total Hospital Costs $410.81 370 - Total Other Medical $4,560.39
450 - Total Pharmaceutical Costs $2,770.40 460 - Total Physical Therapy Costs $1,145.07
470 - Total Durable Medical Costs $102.56
Recoveries
Recovery Type Amount
880 - Voided Indemnity Benefit Check Recovery $9,751.57
CONCURRENT EMPLOYER INFORMATION
Name Contact Business Phone Wage
SROI-SA-R3 (1-14) Page 2 of 2 www.wcb.ny.gov
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
(1)61555114-4
Copies To: Case #G257 7585
Claimant: JOSEPH ITARA
Carrier: Everest National Insurance Co.
Employer: CENTENNIAL ELEVATOR INDUSTRIES
Other: Brand, Brand, Nomberg
Sedgwick Claims Management
CORDIALE ANDREW JONATHAN
Brand, Brand, Nemberg
& Rosenbaum, LLP
622 Third Ave, 7th Floor
New York, NY 10017
JOSEPH ITARA CENTENNIAL ELEVATOR INDUSTRIES Everest National Insurance Co.
520 WEST 56TH STREET INC 477 Martinsville Road
APT 8D 24-35 47TH STREET PO Box 830
NEW YORK, NY 10019 ASTORIA, NY 11103 Liberty Corner, NJ 07938-0830
Brand, Brand, Nomberg Sedgwick Claims Management CORDIALE ANDREW JONATHAN
& Rosenbaum, LLP Services, Inc. 2001 MARCUS AVENUE
622 Third Ave, 7th Floor PO Box 14156 SUITE W170
New York, NY 10017 Lexington, KY 40512 LAKE SUCCESS, NY 11042
EC-23 (4/98) OVER
(1)61555114-4
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
25361918
Information about Payment of Awards
Payment of an award of corspensation
must be issued within 10 days, except where the carrier has filed an
application
to the board for a modification, rescission or review of the award. If payment is not timely, the Board
imposes a penalty equal to 20% of the unpaid compensation (WCL § 25[3][f]). That penalty is payable to the
claimant.
Payment of installracñts of compensation must be issued within 25 days of becoming due, or else the carrier shall
pay an additional amount of 20% of the compensation then due, plus $300, to the claimant, unless the Board
excuses the late payment upon an application by the carrier. WCL § 25(1)(e).
Claimant - JOSEPH ITARA Employer - CENTENNIAL ELEVATOR INDUSTRIES
Social Security No. - Carrier - Everest National Insurance Co.
WCB Case No. - G257 7585 Carrier ID No. - W183693
Date of Accident - 08/13/2019 Carrier Case No. - B9600F6339000101600
District Office - NYC Date of Filing of this Decision- 03/08/2021
ATENCION:
Puede llamar a la oficina de la Junta de Compensacion Obrera, en su area correspondiente, cuyo numero de telefono aparece al
principio de la pagina y pida informacion acerca de su reclamacion(caso).
EC-23 (4/98) Page 2 of 2
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
(2)61555114-4
(2)61555114-4
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021
25361918
STATE OF NEW YORK
WorkeTSi WORKERS'
NEW COMPENSATION BOARD
YORK . PO BOX 5205
STATE CompenSatIOR BINGHAMTON. NY 13902-5205
www.web.ny.gov
Clarissa M. Rodrigues
Chair (877) 632-4996
State of New York - Workers' Compcñsation Board
In regard to JOSEPH ITARA, WCB Case #G257 7585
NOTICE OF DECISION
keep for your records
Workers'
At the Compensation hearing held on 03/03/2021 involving the claim of JOSEPH ITARA at the
Manhattan hearing location, Judge Meghan McKenna made the following decision, findings and directions:
AWARD : The employer or insurance carrier is directed to pay the following awards, less payments already made
by the employer or carrier, for the periods indicated below, unless employer or carrier files an application within 30
days after the date on which the decision was duly filed and served.
for disability over a period of at rate
weeks from to per week the sum of
17.0 11/4/2020 3/3/2021 $934.11 $15,879.87
- Tentative rate.
Carrier to continue payments at $934.11 tentative rate.
FEES:
As lien on above award payable by separate check by carrier TO CLAIMANT'S REPRESENTATIVE
OR ATTORNEY:
Sum of To
$300.00 Brand, Brand, Nomberg
DECISION: RFA-2 is moot as animont has produced up-to-date medical evidence.
The carrier raises labor market attachment, which is held in abeyance due to COVID-19 and a determination on
degree of disability.
The treatment approved by the prior Orders of the Chair are still valid (the treatment was delayed due to COVID).
. No further action is planned by the Board at this time.
*** Continued on next page ***
Claimant - JOSEPH ITARA Employer - CENTENNIAL ELEVATOR INDUSTRIES
Social Security No. - Carrier - Everest National Insurance Co.
WCB Case No. - G257 7585 Carrier ID No. - W183693
Date of Accident - 08/13/2019 Carrier Case No. - B9600F6339000101600
District Office - NYC Date of Filing of this Decision- 03/08/2021
ATENCION:
Puede llamar a la oficina de la Junta de Compensacion Obrera, en su area correspondiente, cuyo numero de telefono aparece al
principio de la pagina y pida informacion acerca de su reclamacion(caso).
EC-23 (4/98) Page 1 of 2
Preview
FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 Exhibit A FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 Workers' "²° State of New York - Compensation Board Subsequent Report of Injury Report Type (MTC) SA-Sub-Annual This paper contains information that has been provided electronically to the Bœrd. Do no_t serve a copy of this on the Board. ErñpIrayee Name JOSEPH ITARA WCB Case Number (JCN) G2577585 Date of Injury 08/13/2019 Claim Administrator Claim Number B9600F6339000101600 A'±±mnce Type Code Date 07/28/2021 WCB Received Date 07/28/2021 Agreement to Cc=parmate IN$URER INFORMATloN FEIN xxxxx0372 Insurer ID W183693 CLAIM ADMINISTRATOR INFORMATION Name SEDGWICK CLAIMS MANAGEMENT SERVICES, INC FEIN xxxxx5608 Claim Rêpic::7.2tive Name AMANDA WATERS Postal Code 40512-4156 Business Phone Number 3154264998 Fax Number E-mail Address AMANDA.WATERS@SEDGWICK.COM Claim Admin ID T100083 El I EOhi EE INi#ORM TION First Name JOSEPH Middle Nc==!::itial Last Name ITARA Suffix Date of Birth 4 =mpicyee ID Type S - Employee Social Security Number Emp|Gyäs ID ××××x7713 BENERTS Benefits 050 - Temporary Total 070 - Temporary Partial Benefits - Cumulative SROI-SA-R3 (1-14) Page 1 of 2 www.wcb.ny.gov FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 S9517120 Start Through Claim Claim Amount Benefit ype Date Date Weeks Days PaK‡ 050 - Temporary Total 08/14/2019 01/03/2020 20 3 $19,242.67 070 - Temporary Partial 01/04/2020 07/16/2021 80 O $74,728.80 Benefits - A - Adjustments / C - Credits / R - Redistributions Other Benefits Other Beneñt Type Amount Other Benefit T ype Amount 340 - Total Claimant's Legal Expenses $1,600.00 350 - Total Payments to Physicians $7,770.49 360 - Total Hospital Costs $410.81 370 - Total Other Medical $4,560.39 450 - Total Pharmaceutical Costs $2,770.40 460 - Total Physical Therapy Costs $1,145.07 470 - Total Durable Medical Costs $102.56 Recoveries Recovery Type Amount 880 - Voided Indemnity Benefit Check Recovery $9,751.57 CONCURRENT EMPLOYER INFORMATION Name Contact Business Phone Wage SROI-SA-R3 (1-14) Page 2 of 2 www.wcb.ny.gov FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 (1)61555114-4 Copies To: Case #G257 7585 Claimant: JOSEPH ITARA Carrier: Everest National Insurance Co. Employer: CENTENNIAL ELEVATOR INDUSTRIES Other: Brand, Brand, Nomberg Sedgwick Claims Management CORDIALE ANDREW JONATHAN Brand, Brand, Nemberg & Rosenbaum, LLP 622 Third Ave, 7th Floor New York, NY 10017 JOSEPH ITARA CENTENNIAL ELEVATOR INDUSTRIES Everest National Insurance Co. 520 WEST 56TH STREET INC 477 Martinsville Road APT 8D 24-35 47TH STREET PO Box 830 NEW YORK, NY 10019 ASTORIA, NY 11103 Liberty Corner, NJ 07938-0830 Brand, Brand, Nomberg Sedgwick Claims Management CORDIALE ANDREW JONATHAN & Rosenbaum, LLP Services, Inc. 2001 MARCUS AVENUE 622 Third Ave, 7th Floor PO Box 14156 SUITE W170 New York, NY 10017 Lexington, KY 40512 LAKE SUCCESS, NY 11042 EC-23 (4/98) OVER (1)61555114-4 FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 25361918 Information about Payment of Awards Payment of an award of corspensation must be issued within 10 days, except where the carrier has filed an application to the board for a modification, rescission or review of the award. If payment is not timely, the Board imposes a penalty equal to 20% of the unpaid compensation (WCL § 25[3][f]). That penalty is payable to the claimant. Payment of installracñts of compensation must be issued within 25 days of becoming due, or else the carrier shall pay an additional amount of 20% of the compensation then due, plus $300, to the claimant, unless the Board excuses the late payment upon an application by the carrier. WCL § 25(1)(e). Claimant - JOSEPH ITARA Employer - CENTENNIAL ELEVATOR INDUSTRIES Social Security No. - Carrier - Everest National Insurance Co. WCB Case No. - G257 7585 Carrier ID No. - W183693 Date of Accident - 08/13/2019 Carrier Case No. - B9600F6339000101600 District Office - NYC Date of Filing of this Decision- 03/08/2021 ATENCION: Puede llamar a la oficina de la Junta de Compensacion Obrera, en su area correspondiente, cuyo numero de telefono aparece al principio de la pagina y pida informacion acerca de su reclamacion(caso). EC-23 (4/98) Page 2 of 2 FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 (2)61555114-4 (2)61555114-4 FILED: NEW YORK COUNTY CLERK 09/10/2021 03:06 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 66 RECEIVED NYSCEF: 09/10/2021 25361918 STATE OF NEW YORK WorkeTSi WORKERS' NEW COMPENSATION BOARD YORK . PO BOX 5205 STATE CompenSatIOR BINGHAMTON. NY 13902-5205 www.web.ny.gov Clarissa M. Rodrigues Chair (877) 632-4996 State of New York - Workers' Compcñsation Board In regard to JOSEPH ITARA, WCB Case #G257 7585 NOTICE OF DECISION keep for your records Workers' At the Compensation hearing held on 03/03/2021 involving the claim of JOSEPH ITARA at the Manhattan hearing location, Judge Meghan McKenna made the following decision, findings and directions: AWARD : The employer or insurance carrier is directed to pay the following awards, less payments already made by the employer or carrier, for the periods indicated below, unless employer or carrier files an application within 30 days after the date on which the decision was duly filed and served. for disability over a period of at rate weeks from to per week the sum of 17.0 11/4/2020 3/3/2021 $934.11 $15,879.87 - Tentative rate. Carrier to continue payments at $934.11 tentative rate. FEES: As lien on above award payable by separate check by carrier TO CLAIMANT'S REPRESENTATIVE OR ATTORNEY: Sum of To $300.00 Brand, Brand, Nomberg DECISION: RFA-2 is moot as animont has produced up-to-date medical evidence. The carrier raises labor market attachment, which is held in abeyance due to COVID-19 and a determination on degree of disability. The treatment approved by the prior Orders of the Chair are still valid (the treatment was delayed due to COVID). . No further action is planned by the Board at this time. *** Continued on next page *** Claimant - JOSEPH ITARA Employer - CENTENNIAL ELEVATOR INDUSTRIES Social Security No. - Carrier - Everest National Insurance Co. WCB Case No. - G257 7585 Carrier ID No. - W183693 Date of Accident - 08/13/2019 Carrier Case No. - B9600F6339000101600 District Office - NYC Date of Filing of this Decision- 03/08/2021 ATENCION: Puede llamar a la oficina de la Junta de Compensacion Obrera, en su area correspondiente, cuyo numero de telefono aparece al principio de la pagina y pida informacion acerca de su reclamacion(caso). EC-23 (4/98) Page 1 of 2