On September 15, 2023 a
EXHIBIT(S) - C (Motion #003) - Initial Intake Questionnaire
was filed
involving a dispute between
In The Matter Of The Claim Of Hilda Altagracia Guzman,
and
The City Of New York,
for Special Proceedings - Other (Trip and Fall)
in the District Court of Queens County.
Preview
FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023
Exhibit C
FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023
Subin Associates
Intake Sheet
ALL of the following fields MUST be filled out OR filled out with N/A (Not Applicable)
- 2-
Today's Date: / Ù
Name of Person filling out this form for Subin Associates: W (n c b
How did the client hear about Subin Associates?
Emergency Contact if Client cannot be reached: (name/number/address/Email)
3' 0Y0 3 ¼ 2._
Inform client that confidentiality prevents disclosure of protected information, this is just emergency contact
IS CLIENT CURRENTLY REPRESENTED BY ANOTHER ATTORNEY FOR THIS MATTER? _ Yes No
If YES, Name of Attorney / Firm:
Address / Phone:
First Name: c Last Name: (7WL m c
Social Security #? Y _ N _ If Yes, Social Security No.: WO
Date of Birth: S / 2 7 Sex: M
Primary Language: English Spanish Other:
Home Address: no ¶ A h
-
Home Telephone #: Cell #: 7 7 42-0 52 Work #:
Please list all Email Addresses: L A PR TETA331 o0wA-L.-
Do you subscribe to any Social Networking Sites, if so, which ones?
If YES, Inform Client we advise not to post ANYTHING to these sites for the duration of the lawsuit, or to take their profile down entirely
Marital Status: Single _ Married ___ Separated ___ Divorced _
Is Client a Minor? If YES, Legal Guardian Name:
Address:
Alternate Contact Person: Relation:
Alternate's Telephone #:
Alternate's Email Address
Spouse/Guardian Info: Relation:
Telephone #: Cell #
Home Address:
Email Address:
FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023
Date of Injury: Time of In ident:
-
Location of Incident: I Î '} T
)
Please escribe the incident C W0 f k-
S w A
Did an Ambulance respond? Y N
Name of Ambulance company
Ambulance report information
Were you taken to a hospital? Y N
Which hospital? U r c4-q
C 6
If not how did you get to the hospital? Or-oM \n.o
by Ambulance,
Please describe your injuries: co × . c nA
Please list the names and addresses of any person(s) who treated the client for these njuries
If hand or arm injured, which is your dominant side: Right Left
had-
Since the accident, have you Headache Y N Dizziness Y N
Blurry Vision Y _ N Nausea or Vomiting Y N
Changes in Behavior Y N _ Disorientation or Memory Loss Y N
Are you CURRENTLY involved in a bankruptcy proceeding? Y _ N
If YES, Court: Case No.
Do you have health insurance currently? If s who is t e rrier and get policy number
%tdhyl -
\ a\ Evýr
Are you a Medicare or Medicaid recipient? (List Numbers or photocopy Card)
If yes, get a signed copy of Medicare and/or Medicaid authorization
Have you had any previous accidents causing injury? Y N
If so, list: date, type of accident, and whether a claim was made
2oN , mve ,
L suaA L Kn
Have you had any previous injuries? If yes, list
Have you had any previous lawsuits? If yes, list
Were you employed at t e time of the accident? Y N _
If YES, were you on the job when the accide t rred? Y N
Employ r Name and Address $ S , MO
Job Title:
Time out of Work Average Weekly Income
Supervisor's Name and Contact Info:
If there is time out of work, get Workers Comp. and/or IRS authorization
Student? Y N
Name and Address of School
Time out of School
FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023
PED Knockdown AA Rear End AA Intersection AA Sideswipe
AA Stop sign __ AA Turn Collision ___ AA Bus/Train
AA Hit & Run AA Other
POLICE: Y N PRECINCT#: ACCIDENT #
Number of Vehicles Involved:
Were you in a car that you hired to drive you? Y __ N ___ If YES, what kind?
Yellow Cab Green Taxi Uber Lyft Other
IF AN APP WAS USED TO ORDER, GET CONFIRMATION INFO
Were there any witnesses to the accident? Get Names/Addresses/Phone Numbers:
Are there any pictures of the vehicles before or after the accident?
Who has the pictures? Get the name and address:
Was there Property damage? Y N
Estimate of Damages:
Name of repair shop where vehicle taken:
Are you the Owner of the Car Involved? Y N If No, Who is?
Were you the Driver of the Car Involved? Y N If No, Who was?
Name of their Insurance Company Policy No.
Do you or does anyone in your home (or where you currently live) own/lease/register a vehicle? Y N
If so, name of person: Policy No.
Name of Insurance Company: SUM Policy Limits:
Obtain a copy of the Declaration Page (Dec Sheet) for this vehicle
No Fault Information:
Insurance Company:
Name of Owner: Plate Number/VIN:
Policy and Claim Number:
Defendant Driver information:
Name:
Address:
Insurance Company: Plate Number:
Defendant Owner Information:
Name:
Address:
Insurance Company: Plate Number:
Additional Information:
FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023
DID POLICE COME TO SCENE? Y N PRECINCT#: ACCIDENT #
Were there any witnesses who saw the condition prior to the accident?
Were there any witnesses to the accident? Get Names/Addresses/Phone Numbers:
Are there excellent pictures of the condition that caused the incident?
If YES, who has the pictures? o
If no, who has been assigned to take the pictures?
What type of building was involved? Commercial Large Residential
Small Residential / 5/9/e b
If residence of client, we need a
copy
of the lease
Was the building city owned, NYCHA, etc.? Y ___ N
If yes, what agency or service?
Was the area of incident adjacent to a park? Y ___ N
d
If yes, name of the park
Was the area of incident near a school? Y ___ N f_
If yes, which school
Was the d ect near a curb, sidewalk, grate, tree well, street sign, street lamp or other metal object?
Y N _ If YES, identify: C
Defendant Information:
Name:
Address:
Insurance Company:
Any Additional Information
Document Filed Date
October 27, 2023
Case Filing Date
September 15, 2023
Category
Special Proceedings - Other (Trip and Fall)
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FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023 Exhibit C FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023 Subin Associates Intake Sheet ALL of the following fields MUST be filled out OR filled out with N/A (Not Applicable) - 2- Today's Date: / Ù Name of Person filling out this form for Subin Associates: W (n c b How did the client hear about Subin Associates? Emergency Contact if Client cannot be reached: (name/number/address/Email) 3' 0Y0 3 ¼ 2._ Inform client that confidentiality prevents disclosure of protected information, this is just emergency contact IS CLIENT CURRENTLY REPRESENTED BY ANOTHER ATTORNEY FOR THIS MATTER? _ Yes No If YES, Name of Attorney / Firm: Address / Phone: First Name: c Last Name: (7WL m c Social Security #? Y _ N _ If Yes, Social Security No.: WO Date of Birth: S / 2 7 Sex: M Primary Language: English Spanish Other: Home Address: no ¶ A h - Home Telephone #: Cell #: 7 7 42-0 52 Work #: Please list all Email Addresses: L A PR TETA331 o0wA-L.- Do you subscribe to any Social Networking Sites, if so, which ones? If YES, Inform Client we advise not to post ANYTHING to these sites for the duration of the lawsuit, or to take their profile down entirely Marital Status: Single _ Married ___ Separated ___ Divorced _ Is Client a Minor? If YES, Legal Guardian Name: Address: Alternate Contact Person: Relation: Alternate's Telephone #: Alternate's Email Address Spouse/Guardian Info: Relation: Telephone #: Cell # Home Address: Email Address: FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023 Date of Injury: Time of In ident: - Location of Incident: I Î '} T ) Please escribe the incident C W0 f k- S w A Did an Ambulance respond? Y N Name of Ambulance company Ambulance report information Were you taken to a hospital? Y N Which hospital? U r c4-q C 6 If not how did you get to the hospital? Or-oM \n.o by Ambulance, Please describe your injuries: co × . c nA Please list the names and addresses of any person(s) who treated the client for these njuries If hand or arm injured, which is your dominant side: Right Left had- Since the accident, have you Headache Y N Dizziness Y N Blurry Vision Y _ N Nausea or Vomiting Y N Changes in Behavior Y N _ Disorientation or Memory Loss Y N Are you CURRENTLY involved in a bankruptcy proceeding? Y _ N If YES, Court: Case No. Do you have health insurance currently? If s who is t e rrier and get policy number %tdhyl - \ a\ Evýr Are you a Medicare or Medicaid recipient? (List Numbers or photocopy Card) If yes, get a signed copy of Medicare and/or Medicaid authorization Have you had any previous accidents causing injury? Y N If so, list: date, type of accident, and whether a claim was made 2oN , mve , L suaA L Kn Have you had any previous injuries? If yes, list Have you had any previous lawsuits? If yes, list Were you employed at t e time of the accident? Y N _ If YES, were you on the job when the accide t rred? Y N Employ r Name and Address $ S , MO Job Title: Time out of Work Average Weekly Income Supervisor's Name and Contact Info: If there is time out of work, get Workers Comp. and/or IRS authorization Student? Y N Name and Address of School Time out of School FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023 PED Knockdown AA Rear End AA Intersection AA Sideswipe AA Stop sign __ AA Turn Collision ___ AA Bus/Train AA Hit & Run AA Other POLICE: Y N PRECINCT#: ACCIDENT # Number of Vehicles Involved: Were you in a car that you hired to drive you? Y __ N ___ If YES, what kind? Yellow Cab Green Taxi Uber Lyft Other IF AN APP WAS USED TO ORDER, GET CONFIRMATION INFO Were there any witnesses to the accident? Get Names/Addresses/Phone Numbers: Are there any pictures of the vehicles before or after the accident? Who has the pictures? Get the name and address: Was there Property damage? Y N Estimate of Damages: Name of repair shop where vehicle taken: Are you the Owner of the Car Involved? Y N If No, Who is? Were you the Driver of the Car Involved? Y N If No, Who was? Name of their Insurance Company Policy No. Do you or does anyone in your home (or where you currently live) own/lease/register a vehicle? Y N If so, name of person: Policy No. Name of Insurance Company: SUM Policy Limits: Obtain a copy of the Declaration Page (Dec Sheet) for this vehicle No Fault Information: Insurance Company: Name of Owner: Plate Number/VIN: Policy and Claim Number: Defendant Driver information: Name: Address: Insurance Company: Plate Number: Defendant Owner Information: Name: Address: Insurance Company: Plate Number: Additional Information: FILED: QUEENS COUNTY CLERK 10/27/2023 03:19 PM INDEX NO. 719177/2023 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 10/27/2023 DID POLICE COME TO SCENE? Y N PRECINCT#: ACCIDENT # Were there any witnesses who saw the condition prior to the accident? Were there any witnesses to the accident? Get Names/Addresses/Phone Numbers: Are there excellent pictures of the condition that caused the incident? If YES, who has the pictures? o If no, who has been assigned to take the pictures? What type of building was involved? Commercial Large Residential Small Residential / 5/9/e b If residence of client, we need a copy of the lease Was the building city owned, NYCHA, etc.? Y ___ N If yes, what agency or service? Was the area of incident adjacent to a park? Y ___ N d If yes, name of the park Was the area of incident near a school? Y ___ N f_ If yes, which school Was the d ect near a curb, sidewalk, grate, tree well, street sign, street lamp or other metal object? Y N _ If YES, identify: C Defendant Information: Name: Address: Insurance Company: Any Additional Information