On June 13, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
Progressive Casualty Insurance Company,
and
Alejandro Mayorga
A K A Alejandro Mayorge A K A Alejandro Mayorga Velazquez,
American Medical Initiatives, P.C.,
Anjani Sinha Medical P.C.,
Atlantic Medical & Diagnostic, P.C.,
Benson Medical P.C.,
Brand Medical Supply, Inc.,
Cross Island Chiropractic Evaluations, P.C.,
Emote Medical Services, P.C.,
Ezrx Chemists Corp.,
Ez Triboro Services, Inc.,
Fast Care Medical Diagnostics, Pllc,
Five Town Tl Medical P.C.,
J Sports Medicine P.C.,
Macintosh Medical, P.C.,
Mega Deal Group Corp,
Nyc Family Chemists Corp.,
Ptj Medical Services P.C.,
Queens Boulevard Chiropractic, P.C.
A K A Queens Boulvard Chiropractic Pc,
Roosevelt Family Chiropractic, P.C.,
Steven Wong, Md,
Warren Street Orthopedic Rehabilitation, P.C.,
Youssef Pt, P.C.,
for Torts - Motor Vehicle
in the District Court of Nassau County.
Preview
FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023
NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 01/26/2024
EXHIBIT “G”
FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023
NYSCEF 04-06-'22
DOC. NO. 46
14:34 FROM- RECEIVED NYSCEF: 01/26/2024
Helen Dalton & Ass. 718-263-9598 T-850 P0009/0012 F-346
... . . ._.. . . . . . ., -.. .. .... . . .. . . .... . . .......-.. . .. ......-....... - ...-... .. . .... .... . - -- -- .......-...--.. -.- -. - . ... .. . . .
NEW YORK MOTOR VGHICLE NO-FAULT tNSU RANCE t..AW
AP LICATION F'OR NOTOR EMICLE NO-FAULT BENEFIT
NAME AND ADDRESS QF INSURER , EE, ADDRESS. MD MBER me mR
CLAIMS REPRESENTATIVE
DATE DATE OF ACC DEN · CLAIM NuNIBER
POUCYHOLDER. POLICY NUMBER
TÔ ENABLE US TO DETERMINE tF YOUR ARE ENTITLED TO BENGFtTS UNDER THE NEW YORK NOfAULT LAW,
PLEASE COMPLETE T14IS FORM AND RETURN tT PROMPTLY,
IMPORTANT- 1. TO SC EL4Gl8L.E FOR BENEFITS YOU MUST COMPLETE AND SIGN WIS APPLICATION.
2L YOU MUST SIGN ANY.ATTACHED AUTHORIZATION(S).
. 3. ftEIUMN PROMPTLY iNint COPIE!9 OF ANY BILLS YOU tiAVE RECEiVED TO DATE..
Name AND AD.ORESS OF APPUCAKF
1. YOUS.t¾WIE 2, PHONE NOS, (40ME BUSINESS
R. 4. DATE OF BIRTH 5, oclAL SECUAITY NO.
(NO¾ STSEET CITY ORTOWN Antp aP CODE)
& 'fE OF 7 PI.A0Ê ÓF ACCIDENT (STRE CrTY OR TOWN AND:8TATE
R"
3/9/tt
e. eRIEF OESCRIFriON OF ACCIDENT
6. ftscamayoun uunv
. IDENTITV O VEHlOLIE VÖU MbC(.JiSlËÖ Ok OREWA T tHE M O THÈi ACCIDEN
QWNEEUS NAME MAEE )Tag
TE!!S VEntCLE WAS- AN AUTOMOBILE,
A BUS OR SCHOOL BUS. A TRUCK
OR A MOTORCYCLE
YE3 NO
11. WERE YOU TNE GRIVER OF THE MOTOR VEHICLE?
WERE YO(.A A PASSliNGER IN THE MOTOR VEHICLE?
WERE YOU A PEDESTRIAN?
WERE YOU A MEMBER or OUR POLICYN OLDER'S ‰OUSBHOLDT a---
Do YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE? ,--
CONTINUATION ON NEXT PAGE
NYS FORM NF-2 (Rev 1/2004)
Page 1 of 3
FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023
NYSCEF 04-06-'22
DOC. NO. 46
14:34 FROM- RECEIVED NYSCEF: 01/26/2024
Helen Dalton & Ass. 718-263-9598 T-850 P0010/0012 F-346
APPLLCATION FOR MOTOR VEHICLE NQ-FAULT B.ENEFITS - - PAGE TWO
11WEREYOUTMÈATED BY A DOCT&R(8) OR OTHER PERSON($) FURt SHINO FIGALTH SERVICES1
YES NO
IF YES. NAME AND ADDRESS OF SucH DOCTOR(S) OR PERSON(s):
13. IF YOUR WERÈ TREATED AT A HO$PITAL(Z), WERÈ YOU AN
OUT-PATLENT? IN--PATIENT
DATE OF ADMISSION:
fiOSP2TACS NAME AND ADDRESS:
14, AMOUNT OF HEALTH b.wsu. YovNAW IdOREMEALTH 16, ATH TIME OF VOUT ACCIDÈÑT WETE
GlLLS TO DATE- TREATMENT(Sp YOU IN THG COURSE OF YOUR
s
YES
g
/ NO EMPLOYMENT1
. Yes NO
g
reÄ6süiöëW5B-- -
o.orntouLoseTsuE AAVE Y6U METURNEO16
PRouwoan? WORK BEGAN: WORK?
YI2S . NO YES No
tF YES.DATE REiTURNED TO %DRK· AMOUtff >F TME LOST FROM W1RK
%W41ATAREYOOEGR6$$AVEhAQE idilMBER OF OAYS YOU WORK NUMBEROFHOURS YOU WORK
WEEKLY EARNINGS? PER V62EK: PER DAY:
19. GRE YOU RECEMNÔ UNEMPLOVNGNT nENERTS AT THEDME65 THE ACCIDENT?
YES NO
20. 11STNMidfB1ÃN0 AnhNEss69toúREMPh3 R-ÃÑ50theÈEEAM-6VEX$ FóM ONeY£iAR PRIOAM
ACC(OENT DATE.AND GLVE OCCUPATION ANODATES OF EMPLOYMENT;
EMPLOYEiR AND ADDRESS OCCUpANON FROM TO
EMPLOYER AND ADDRESS Od UHATION FROM TO
EMPLOVER AND ADDRESS OCCUPATION FROM TO
'
2t AS A NESULT OF YOUR INJURY HAVE YOU MAD AHV 6TSER EXÞENBEM
YES NO _ _[
IF Y6S, ATTACH litXPLANATloN, AND AMOUNTS OF SUCH EXPENpÇ$,
22. pUGf TO h-113 AcetDENT HAVf VÒU REd VEb OR AX YOU EllGlBLÈ FOR PAYMENTS
UNDER ANY OF THE FOLLOWING:
YEp NO/
NEW YORK 5TATE Di5AlpiuTY?
WORKERS' COMPENSATLON?
CONYtNUATSON ON NEXT PAGE
tvYS PORM NF-2 (Rev 1f2Q04)
Page 2 of 3
FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023
NYSCEF 04-06-'22
DOC. NO. 14:35
46 FROM- Helen Dalton & Ass. 718-263-9598
RECEIVED
T-850
NYSCEF: F-346
P0011/0012
01/26/2024
APPLICATION FOR MOTOR VEHiCLE NOfAULT BENEFITS - -PAGE.TtiREE
TFE APPLICANT AUTHORIZEs TI-lE INSURER TO SUSMIT A‚ AND ALL OF THESE FORMS TO ANOTHER PARTY
OR INSURER IF $UCH IS NECESSARY TO PERFECT ITS REGHTS OF RECOVERY PROVIDED FOR UNDER THE
NO-FAULT LAW.
THIS FORM IS SUBSÒRIBED AND AFRRMED BY THE
APPL(CANT AS TRUE UNDER THE PENALTIES OF PERJURY
DEFRAUD'
ANY PER,SON WHO KNOWINGLY AND WITt4 INYENT TO ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMNLERCIAL (NSURANCE OR A STATEMENT OF CLAIM FOR ANY
COIMMERCIAL OR PERSONAL INSURANCE BENEF1TS. CONTAINING ANY MATERIALLY FALSE INFORMATioN,
OR CQIQCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, 40 A$(Y-PERSON WHO, IN CONNECTIOt4 WITH SUCH APEt.ICATION OR CLAl.M. KNOWINGLY
élAKES QR tiiMOWINGLY ASSISTS. ABETS, SOtJCITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE
REPòf7P OF 'THE THEFT, DÈiSTRUCTION, DAMAGE OR CONVENStoN OF ANY MOTOR VEI CtE TO A t;AW
ENFORCEMˆM.T AGENCY, THE DEPARTMENT OF MOTOR OR AN (NSURANCE
VENICLES COMPANY,
COMMITS.A f%AUDts.ENT INSURANCE ACT, WHtCH IS A CRIME, AND SH.ALL ALSO BE SUBJECT TO A CML .
. PEiMAtE4107Tb.EXCEED FIVE THOUSAND DOtJ-ARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE
ORSTATED CLAIM FOR EACH VIOLATIOtt
OS o6 ?^J--
$1GNATURE DATE
DONOT t)ETACH
AA.fTHORIZAT4ON FOR RELEASE OF WORK AND OTHER LOSS tNFORMATION
'THIS AUTHORIZATION OR PtiOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNt5M ALL INFORMATION YOU MAY
HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLO'yED BY YOU. YOUR ARE AUTHORtZEO TO
PROVIDE This INFORMATION IN ACCORDANCE WITH THE NEW YORK. COMPREHENSIVE MOTOR VEfitCLE
INSURAMCG REPARATIONS ACT (NO-FAULT LAW).
Pf1 N .
a
NAME OR . PE) sOCIAL SÊCU8 No.
o3 pe
. H a
StoblAtURE DATE
FOR RELGASE QF HEALTH.SERVICE
AUTHORIZATiON OR TREATMENT (NFORMATION
THIS AUTHORIZATION OR PROTOCOpy THEREOF. WiU.. AUTHORiZE YOU TO FifRNISH At.L INFORMATION YOU MAY
HAVE REGAftDING MY CONDETION WHILE UNDER YOUR OBsERVATION. OR TREATMENT, INCLUDING THE MISTORY
OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGivOSIS AND P8QGNOSIS. YOU ARG AUTHORI2EO .TO PROVIDE
THIS INFORMATION IN ACCORDANCE WITH YME NEW YORK COMPREHENSlVE MOTOR VEHicLE INSURANCE
REPARATIONS ACT (NO#AULT LAW),
NAME (PRLNT OR WPE)
SIGNATURE DATE
(1F THE APPLICANT 18 A MINOR, PARENT OR GUARDIAN SHALL $lGN AND INDICATE CAPACITY AND RELATION$HIP).
't.ANGUAGE TO BE RLLED IN BY !NSURER OR SELF4NSURER.
NY S FORM NP-2 (Rev 1/20Q4)
Page 3 of 3
Document Filed Date
January 26, 2024
Case Filing Date
June 13, 2023
Category
Torts - Motor Vehicle
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023 NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 01/26/2024 EXHIBIT “G” FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023 NYSCEF 04-06-'22 DOC. NO. 46 14:34 FROM- RECEIVED NYSCEF: 01/26/2024 Helen Dalton & Ass. 718-263-9598 T-850 P0009/0012 F-346 ... . . ._.. . . . . . ., -.. .. .... . . .. . . .... . . .......-.. . .. ......-....... - ...-... .. . .... .... . - -- -- .......-...--.. -.- -. - . ... .. . . . NEW YORK MOTOR VGHICLE NO-FAULT tNSU RANCE t..AW AP LICATION F'OR NOTOR EMICLE NO-FAULT BENEFIT NAME AND ADDRESS QF INSURER , EE, ADDRESS. MD MBER me mR CLAIMS REPRESENTATIVE DATE DATE OF ACC DEN · CLAIM NuNIBER POUCYHOLDER. POLICY NUMBER TÔ ENABLE US TO DETERMINE tF YOUR ARE ENTITLED TO BENGFtTS UNDER THE NEW YORK NOfAULT LAW, PLEASE COMPLETE T14IS FORM AND RETURN tT PROMPTLY, IMPORTANT- 1. TO SC EL4Gl8L.E FOR BENEFITS YOU MUST COMPLETE AND SIGN WIS APPLICATION. 2L YOU MUST SIGN ANY.ATTACHED AUTHORIZATION(S). . 3. ftEIUMN PROMPTLY iNint COPIE!9 OF ANY BILLS YOU tiAVE RECEiVED TO DATE.. Name AND AD.ORESS OF APPUCAKF 1. YOUS.t¾WIE 2, PHONE NOS, (40ME BUSINESS R. 4. DATE OF BIRTH 5, oclAL SECUAITY NO. (NO¾ STSEET CITY ORTOWN Antp aP CODE) & 'fE OF 7 PI.A0Ê ÓF ACCIDENT (STRE CrTY OR TOWN AND:8TATE R" 3/9/tt e. eRIEF OESCRIFriON OF ACCIDENT 6. ftscamayoun uunv . IDENTITV O VEHlOLIE VÖU MbC(.JiSlËÖ Ok OREWA T tHE M O THÈi ACCIDEN QWNEEUS NAME MAEE )Tag TE!!S VEntCLE WAS- AN AUTOMOBILE, A BUS OR SCHOOL BUS. A TRUCK OR A MOTORCYCLE YE3 NO 11. WERE YOU TNE GRIVER OF THE MOTOR VEHICLE? WERE YO(.A A PASSliNGER IN THE MOTOR VEHICLE? WERE YOU A PEDESTRIAN? WERE YOU A MEMBER or OUR POLICYN OLDER'S ‰OUSBHOLDT a--- Do YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE? ,-- CONTINUATION ON NEXT PAGE NYS FORM NF-2 (Rev 1/2004) Page 1 of 3 FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023 NYSCEF 04-06-'22 DOC. NO. 46 14:34 FROM- RECEIVED NYSCEF: 01/26/2024 Helen Dalton & Ass. 718-263-9598 T-850 P0010/0012 F-346 APPLLCATION FOR MOTOR VEHICLE NQ-FAULT B.ENEFITS - - PAGE TWO 11WEREYOUTMÈATED BY A DOCT&R(8) OR OTHER PERSON($) FURt SHINO FIGALTH SERVICES1 YES NO IF YES. NAME AND ADDRESS OF SucH DOCTOR(S) OR PERSON(s): 13. IF YOUR WERÈ TREATED AT A HO$PITAL(Z), WERÈ YOU AN OUT-PATLENT? IN--PATIENT DATE OF ADMISSION: fiOSP2TACS NAME AND ADDRESS: 14, AMOUNT OF HEALTH b.wsu. YovNAW IdOREMEALTH 16, ATH TIME OF VOUT ACCIDÈÑT WETE GlLLS TO DATE- TREATMENT(Sp YOU IN THG COURSE OF YOUR s YES g / NO EMPLOYMENT1 . Yes NO g reÄ6süiöëW5B-- - o.orntouLoseTsuE AAVE Y6U METURNEO16 PRouwoan? WORK BEGAN: WORK? YI2S . NO YES No tF YES.DATE REiTURNED TO %DRK· AMOUtff >F TME LOST FROM W1RK %W41ATAREYOOEGR6$$AVEhAQE idilMBER OF OAYS YOU WORK NUMBEROFHOURS YOU WORK WEEKLY EARNINGS? PER V62EK: PER DAY: 19. GRE YOU RECEMNÔ UNEMPLOVNGNT nENERTS AT THEDME65 THE ACCIDENT? YES NO 20. 11STNMidfB1ÃN0 AnhNEss69toúREMPh3 R-ÃÑ50theÈEEAM-6VEX$ FóM ONeY£iAR PRIOAM ACC(OENT DATE.AND GLVE OCCUPATION ANODATES OF EMPLOYMENT; EMPLOYEiR AND ADDRESS OCCUpANON FROM TO EMPLOYER AND ADDRESS Od UHATION FROM TO EMPLOVER AND ADDRESS OCCUPATION FROM TO ' 2t AS A NESULT OF YOUR INJURY HAVE YOU MAD AHV 6TSER EXÞENBEM YES NO _ _[ IF Y6S, ATTACH litXPLANATloN, AND AMOUNTS OF SUCH EXPENpÇ$, 22. pUGf TO h-113 AcetDENT HAVf VÒU REd VEb OR AX YOU EllGlBLÈ FOR PAYMENTS UNDER ANY OF THE FOLLOWING: YEp NO/ NEW YORK 5TATE Di5AlpiuTY? WORKERS' COMPENSATLON? CONYtNUATSON ON NEXT PAGE tvYS PORM NF-2 (Rev 1f2Q04) Page 2 of 3 FILED: NASSAU COUNTY CLERK 01/26/2024 11:33 AM INDEX NO. 609324/2023 NYSCEF 04-06-'22 DOC. NO. 14:35 46 FROM- Helen Dalton & Ass. 718-263-9598 RECEIVED T-850 NYSCEF: F-346 P0011/0012 01/26/2024 APPLICATION FOR MOTOR VEHiCLE NOfAULT BENEFITS - -PAGE.TtiREE TFE APPLICANT AUTHORIZEs TI-lE INSURER TO SUSMIT A‚ AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF $UCH IS NECESSARY TO PERFECT ITS REGHTS OF RECOVERY PROVIDED FOR UNDER THE NO-FAULT LAW. THIS FORM IS SUBSÒRIBED AND AFRRMED BY THE APPL(CANT AS TRUE UNDER THE PENALTIES OF PERJURY DEFRAUD' ANY PER,SON WHO KNOWINGLY AND WITt4 INYENT TO ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMNLERCIAL (NSURANCE OR A STATEMENT OF CLAIM FOR ANY COIMMERCIAL OR PERSONAL INSURANCE BENEF1TS. CONTAINING ANY MATERIALLY FALSE INFORMATioN, OR CQIQCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, 40 A$(Y-PERSON WHO, IN CONNECTIOt4 WITH SUCH APEt.ICATION OR CLAl.M. KNOWINGLY élAKES QR tiiMOWINGLY ASSISTS. ABETS, SOtJCITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPòf7P OF 'THE THEFT, DÈiSTRUCTION, DAMAGE OR CONVENStoN OF ANY MOTOR VEI CtE TO A t;AW ENFORCEMˆM.T AGENCY, THE DEPARTMENT OF MOTOR OR AN (NSURANCE VENICLES COMPANY, COMMITS.A f%AUDts.ENT INSURANCE ACT, WHtCH IS A CRIME, AND SH.ALL ALSO BE SUBJECT TO A CML . . PEiMAtE4107Tb.EXCEED FIVE THOUSAND DOtJ-ARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE ORSTATED CLAIM FOR EACH VIOLATIOtt OS o6 ?^J-- $1GNATURE DATE DONOT t)ETACH AA.fTHORIZAT4ON FOR RELEASE OF WORK AND OTHER LOSS tNFORMATION 'THIS AUTHORIZATION OR PtiOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNt5M ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLO'yED BY YOU. YOUR ARE AUTHORtZEO TO PROVIDE This INFORMATION IN ACCORDANCE WITH THE NEW YORK. COMPREHENSIVE MOTOR VEfitCLE INSURAMCG REPARATIONS ACT (NO-FAULT LAW). Pf1 N . a NAME OR . PE) sOCIAL SÊCU8 No. o3 pe . H a StoblAtURE DATE FOR RELGASE QF HEALTH.SERVICE AUTHORIZATiON OR TREATMENT (NFORMATION THIS AUTHORIZATION OR PROTOCOpy THEREOF. WiU.. AUTHORiZE YOU TO FifRNISH At.L INFORMATION YOU MAY HAVE REGAftDING MY CONDETION WHILE UNDER YOUR OBsERVATION. OR TREATMENT, INCLUDING THE MISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGivOSIS AND P8QGNOSIS. YOU ARG AUTHORI2EO .TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH YME NEW YORK COMPREHENSlVE MOTOR VEHicLE INSURANCE REPARATIONS ACT (NO#AULT LAW), NAME (PRLNT OR WPE) SIGNATURE DATE (1F THE APPLICANT 18 A MINOR, PARENT OR GUARDIAN SHALL $lGN AND INDICATE CAPACITY AND RELATION$HIP). 't.ANGUAGE TO BE RLLED IN BY !NSURER OR SELF4NSURER. NY S FORM NP-2 (Rev 1/20Q4) Page 3 of 3