On December 21, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
Progressive Advanced Insurance Company,
and
Canal Insurance Company
Proposed Additional Respondent,
Freedom Trans Corp.
Proposed Additional Respondent,
Josue I. Velis Ventura,
Kenneth L. Jacobs
Proposed Additional Respondent,
Shark Logistics Corp.
Proposed Additional Respondent,
for Special Proceedings - CPLR Article 75
in the District Court of Suffolk County.
Preview
FILED: SUFFOLK COUNTY CLERK 12/21/2023 12:31 PM INDEX NO. 631416/2023
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 12/21/2023
EXHIBIT “C”
FILED: SUFFOLK COUNTY CLERK 12/21/2023 12:31 PM INDEX NO. 631416/2023
NYSCEF DOC. NO. 5 DEPART RECEIVED NYSCEF: 12/21/2023
STATE
OF1 P E NEW YORK
M°Toave
POLICE ACCID sates
uv REPORT
10H2OV6N O AMENCEO REPORT
------ --- -
. ACGCENT legy as wggg IMrdTARY HME N.O. C MOU9ED
DATE
VEPICLE5 4LLED POLK-E PHOTOS
NOT
MVE5TIGATEQ AT SCENE
DAY yp_4_t
2 0
O
OS 2023 Tuesday 18:20 0 emascoasm,-a o
VEM PEDESTRIAN OTHERPEDESTRIAN
2 .BICYCLIST
E 1 - DRAT-R 5TATF 0F
L.l
VE-
2 I - ERNER
5-Ex--
gp m
2. GNSE M M.IMBER E (D Numn NY
hAM - EXACTL-Y
-7AMR hEa· ·'¾ME - EXAftty
A5 MD'ED ON UCENSE PARKED Outeer KENNETH L 4
JACOBS,
ADDRES5 ING.4,IQE NUMBER AND $EREE· °*6s
E NO.
UNCLUC$ NUWIQER AND 5T'REE·
1 W
m
FARMS SQUARE 2N
MDE
cr v oR STATE ZIP CODE try op "h 50
NY 104600000
BRONX
No. DF CCCiM¾NffS 8 C
f D . NG· OF GCClWN'-5 SEx UFC.ECENSED
. OATE OF MTH
01
00 M
- -
P-
.
SEX DATE OF B,1RTH
NAM - EXACT'-r ½ ENt GD DN R-G"SIRMWr, 3ATE OF EiJRD-1 .Me - ExacT1-y a e .,,s .a ON REGi5TRARCM
190NTH OAV VF-AR
- JOSUE I HARK LOGISTICS CORP
VEELISVENTURA, . HELEA-
ifAiCLUGE· INUMEIC-R.AND STREED APT. NO,1-tAZ, g 7
ff-'GRE55 OM-LU3E M.MBER PC STREE APT. so. I-pAZ- g. REli D ADDF.ESS
r. _
TAT'
GREEN
FULTON $T - Ï
O 1192 5T
5[AT E 27 CGGE
STATE 2]P CODE CEP CR -OVtN
NJ 08830
11717 ISELIN
BRENTWOOD NY
TYP5 INS. CODE
SIMF OF RIS VEMICLE YEAR 5. MME vtHEO.E
vä r-S· aiEG. VEH1CL.E YEAR & MMB ./El-LEn-E TYPE WS. CO-E i.ATE r4MBEA.
- P1.ATE hoMBER
2018 FRED TRAC 989
4DSD 6c8 AY3583 NJ
JRA9938 NY 2009 NISS ;
nof:;AAREST 4410H20WDP
-' 4410H20WRL,
UCK--T/ARRE51
uwas) 4410M20WTH,
M×eER3N
cowson
viananm 5091, 340A,
5111A
sEcp_onts)
SECTICMsi
ETKl-E THE C Gas sutaw '-tigr anjP,es THE M.umIT, on estamivcum.cas
I
CFIECUF WVOLVr..D VDIRE'-E
!5- CHECK [F ENVOLVED VEMEQ.E Fli & NUM-R MEE.M
ar¬s mem -relE5WrCE NfPE im95 mr.HE5 WIDE;
*K* -IÄ mm "" 5
E- "0
c E TNAN 5 F w½·· E
90
,,,,
RAS W-H F C ·T -ERMO - .5
H epEam-t- #T-rl O 0YEF.½GLW FEi-©,
f
TI--
4i3E-- ED W:TH Kr PERDiere.2.-Ib. iM¶
O.TEATED al--I Nd EiVfGrW.½•ON PE DAMA-- U-F
E)rt:u 2 CBCES DE5nW
21
vëiaICLE 1 0AvGE CCDE5
L BCN E - 9ORT OF PPACT
E eax E - p0y T 0F R1FAC gon - MOST Dam 2 2 2.
- OAMAG _
Box 2 MO57
-CIDENT 'MACRAM.
E RD S
CLE EiY
WEPHELE BC To va C
r0 ED TO
DIAGAAM I R-i287
E-13 5EE 2 TO ANY CNE VEMC-E WN,, SE MORE TI;íAN $1#00-
COST 0F B2P495
ygEACJiRRIAGE 17. DEMOL.f5HE
p.
TRA1LER 18. NO DAMAGE TO DEIERMI
H. NKL'C'/'MjNABLE
19, OTHER L.2 10
OVERTURNED
16.
PLAQ WHERE. ACCf3ENT Oct
mogrMMATEGIWAltMLfl
ELL VN SUFFOLK.
EmeCE MARKER -
REF
mTi.Mem goo on asICH AmlDETF WOODS RD
AC SINEONE
R013% blUMBER OR $TREET VME
VF 1) W-iqR5ECWG
- $TREET
(ROUTENLIMBEITOR NAME)
OR 2) 20
FEE-
ROLITENUMBEROR GTREE,T NAME)
NEARF-st INTEREF-CTING .,
E (MLEPOST,
Or¥OFFKER $ NOTES
Amp¬NT C 5CREFT REPORTS KE
EIARKING LOT . OPERATOR CLEANI|gg. PARKING LOT - OF 2
PARKEfJ N/B IN VEgICLE . VEH 2 PA$LKED W/B IH
ygg -t
FARK OR TRIW5PORTED
EAD T HE VEEICLE In EMERGENCT 2 TO ROLL INTO VEN 1 . OF 1
gays 1967 BLED CAUSING VEN
OCt5PITAL VIA CIEVA RESCUE fDR C
To Sot/Ts 5 TDs
-' 13 H 15
g
4 1 M - -
3ACOBS,
KENNETH L
2 1
L
mu"
Itt.
nos ygScuse, 8) 2023
ROBERT 10:30
5TREZZA 406
-----
-, , 708he 1
FILED: SUFFOLK COUNTY CLERK 12/21/2023 12:31 PM INDEX NO. 631416/2023
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 12/21/2023
INFORMATl0N EXCHANGE PORM
ACCIDENT
darnage any person
ar
M State a reques it·at ar·, accident 'esu t na in a fatal>ty injury
within acciderit.
(includin9 da
age to your vehicie) or entity over
Vehicles (DMV) Fafldr
-)ecartmern of Motor accident or fallore to gwe correcl.
M000 be reoc ted ca YOU to the susoensiori'revo:3tiarr of y0W G for d an
operatin
misciemêarior result 1r the arid all vehicle certifications
'*maSon .s a and may edge in NYS)
CF registrat.iors
Vehicle M°ident).
Motor Ponce DO NŒT
on DMV form MV-104 (Report of Accident ferrn MV-104A)
Report your Acc>dent to Dfsiv Reports (DMV
requiŠement.
satisfy YOUR civihan reportirig
-
gh.
-i--y,-Xo-g- -- --
Date Time -or Town,
Acc dent Report # -Local Codes ,-,
w M_3sr-,
-
.v oniosino2a 6 2 CF - -s ni o S:MONE WOODS RD
Name/BadgeD#
Police Agency Officers
_
- '
S- F DI. ....'..-> :-. .T.-1 -f=ZZA -RAf·,C 7!¹B71'5
_
VEHICLE # r
. _ __ __ --
-operator's Name
ate of Birth Address
C:r State Zip :
Motorist I.D.# Veii e Year and Make License Plate # and State
Niss .1HAU9%
-a
V--: ic Type bsurance Code and Compmy Owner
VehicIn
-- . c : --
=-sy e-
e.wct-r 8.©-
v=_ s #3
TI AI4.:!ê Ï illWi. 4
By
ellanecius Notes
:.i-
Document Filed Date
December 21, 2023
Case Filing Date
December 21, 2023
Category
Special Proceedings - CPLR Article 75
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED: SUFFOLK COUNTY CLERK 12/21/2023 12:31 PM INDEX NO. 631416/2023 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 12/21/2023 EXHIBIT “C” FILED: SUFFOLK COUNTY CLERK 12/21/2023 12:31 PM INDEX NO. 631416/2023 NYSCEF DOC. NO. 5 DEPART RECEIVED NYSCEF: 12/21/2023 STATE OF1 P E NEW YORK M°Toave POLICE ACCID sates uv REPORT 10H2OV6N O AMENCEO REPORT ------ --- - . ACGCENT legy as wggg IMrdTARY HME N.O. C MOU9ED DATE VEPICLE5 4LLED POLK-E PHOTOS NOT MVE5TIGATEQ AT SCENE DAY yp_4_t 2 0 O OS 2023 Tuesday 18:20 0 emascoasm,-a o VEM PEDESTRIAN OTHERPEDESTRIAN 2 .BICYCLIST E 1 - DRAT-R 5TATF 0F L.l VE- 2 I - ERNER 5-Ex-- gp m 2. GNSE M M.IMBER E (D Numn NY hAM - EXACTL-Y -7AMR hEa· ·'¾ME - EXAftty A5 MD'ED ON UCENSE PARKED Outeer KENNETH L 4 JACOBS, ADDRES5 ING.4,IQE NUMBER AND $EREE· °*6s E NO. UNCLUC$ NUWIQER AND 5T'REE· 1 W m FARMS SQUARE 2N MDE cr v oR STATE ZIP CODE try op "h 50 NY 104600000 BRONX No. DF CCCiM¾NffS 8 C f D . NG· OF GCClWN'-5 SEx UFC.ECENSED . OATE OF MTH 01 00 M - - P- . SEX DATE OF B,1RTH NAM - EXACT'-r ½ ENt GD DN R-G"SIRMWr, 3ATE OF EiJRD-1 .Me - ExacT1-y a e .,,s .a ON REGi5TRARCM 190NTH OAV VF-AR - JOSUE I HARK LOGISTICS CORP VEELISVENTURA, . HELEA- ifAiCLUGE· INUMEIC-R.AND STREED APT. NO,1-tAZ, g 7 ff-'GRE55 OM-LU3E M.MBER PC STREE APT. so. I-pAZ- g. REli D ADDF.ESS r. _ TAT' GREEN FULTON $T - Ï O 1192 5T 5[AT E 27 CGGE STATE 2]P CODE CEP CR -OVtN NJ 08830 11717 ISELIN BRENTWOOD NY TYP5 INS. CODE SIMF OF RIS VEMICLE YEAR 5. MME vtHEO.E vä r-S· aiEG. VEH1CL.E YEAR & MMB ./El-LEn-E TYPE WS. CO-E i.ATE r4MBEA. - P1.ATE hoMBER 2018 FRED TRAC 989 4DSD 6c8 AY3583 NJ JRA9938 NY 2009 NISS ; nof:;AAREST 4410H20WDP -' 4410H20WRL, UCK--T/ARRE51 uwas) 4410M20WTH, M×eER3N cowson viananm 5091, 340A, 5111A sEcp_onts) SECTICMsi ETKl-E THE C Gas sutaw '-tigr anjP,es THE M.umIT, on estamivcum.cas I CFIECUF WVOLVr..D VDIRE'-E !5- CHECK [F ENVOLVED VEMEQ.E Fli & NUM-R MEE.M ar¬s mem -relE5WrCE NfPE im95 mr.HE5 WIDE; *K* -IÄ mm "" 5 E- "0 c E TNAN 5 F w½·· E 90 ,,,, RAS W-H F C ·T -ERMO - .5 H epEam-t- #T-rl O 0YEF.½GLW FEi-©, f TI-- 4i3E-- ED W:TH Kr PERDiere.2.-Ib. iM¶ O.TEATED al--I Nd EiVfGrW.½•ON PE DAMA-- U-F E)rt:u 2 CBCES DE5nW 21 vëiaICLE 1 0AvGE CCDE5 L BCN E - 9ORT OF PPACT E eax E - p0y T 0F R1FAC gon - MOST Dam 2 2 2. - OAMAG _ Box 2 MO57 -CIDENT 'MACRAM. E RD S CLE EiY WEPHELE BC To va C r0 ED TO DIAGAAM I R-i287 E-13 5EE 2 TO ANY CNE VEMC-E WN,, SE MORE TI;íAN $1#00- COST 0F B2P495 ygEACJiRRIAGE 17. DEMOL.f5HE p. TRA1LER 18. NO DAMAGE TO DEIERMI H. NKL'C'/'MjNABLE 19, OTHER L.2 10 OVERTURNED 16. PLAQ WHERE. ACCf3ENT Oct mogrMMATEGIWAltMLfl ELL VN SUFFOLK. EmeCE MARKER - REF mTi.Mem goo on asICH AmlDETF WOODS RD AC SINEONE R013% blUMBER OR $TREET VME VF 1) W-iqR5ECWG - $TREET (ROUTENLIMBEITOR NAME) OR 2) 20 FEE- ROLITENUMBEROR GTREE,T NAME) NEARF-st INTEREF-CTING ., E (MLEPOST, Or¥OFFKER $ NOTES Amp¬NT C 5CREFT REPORTS KE EIARKING LOT . OPERATOR CLEANI|gg. PARKING LOT - OF 2 PARKEfJ N/B IN VEgICLE . VEH 2 PA$LKED W/B IH ygg -t FARK OR TRIW5PORTED EAD T HE VEEICLE In EMERGENCT 2 TO ROLL INTO VEN 1 . OF 1 gays 1967 BLED CAUSING VEN OCt5PITAL VIA CIEVA RESCUE fDR C To Sot/Ts 5 TDs -' 13 H 15 g 4 1 M - - 3ACOBS, KENNETH L 2 1 L mu" Itt. nos ygScuse, 8) 2023 ROBERT 10:30 5TREZZA 406 ----- -, , 708he 1 FILED: SUFFOLK COUNTY CLERK 12/21/2023 12:31 PM INDEX NO. 631416/2023 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 12/21/2023 INFORMATl0N EXCHANGE PORM ACCIDENT darnage any person ar M State a reques it·at ar·, accident 'esu t na in a fatal>ty injury within acciderit. (includin9 da age to your vehicie) or entity over Vehicles (DMV) Fafldr -)ecartmern of Motor accident or fallore to gwe correcl. M000 be reoc ted ca YOU to the susoensiori'revo:3tiarr of y0W G for d an operatin misciemêarior result 1r the arid all vehicle certifications '*maSon .s a and may edge in NYS) CF registrat.iors Vehicle M°ident). Motor Ponce DO NŒT on DMV form MV-104 (Report of Accident ferrn MV-104A) Report your Acc>dent to Dfsiv Reports (DMV requiŠement. satisfy YOUR civihan reportirig - gh. -i--y,-Xo-g- -- -- Date Time -or Town, Acc dent Report # -Local Codes ,-, w M_3sr-, - .v oniosino2a 6 2 CF - -s ni o S:MONE WOODS RD Name/BadgeD# Police Agency Officers _ - ' S- F DI. ....'..-> :-. .T.-1 -f=ZZA -RAf·,C 7!¹B71'5 _ VEHICLE # r . _ __ __ -- -operator's Name ate of Birth Address C:r State Zip : Motorist I.D.# Veii e Year and Make License Plate # and State Niss .1HAU9% -a V--: ic Type bsurance Code and Compmy Owner VehicIn -- . c : -- =-sy e- e.wct-r 8.©- v=_ s #3 TI AI4.:!ê Ï illWi. 4 By ellanecius Notes :.i-