On September 05, 2023 a
EXHIBIT(S) - A (Motion #001) - Exhibit A - Police Report
was filed
involving a dispute between
Allstate Insurance Company,
and
Jennifer Goldstein,
for Special Proceedings - CPLR Article 75
in the District Court of Nassau County.
Preview
FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024
Exhibit “A”
FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024
Page1 of 2 Pages NewYork State Departmentof Motor Vehicles
Precinct POLICE ACCIDENT REPORT (NYC) 19
073 MV-104AN (7/11) 13
AccidentNo. Complaint
MV-2020-073 -001335 Number ¡ AMENDED REPORT
DayofWeek MIlltaryTime No.of No.Injured
No.Killed NotInvestigated atScene LeftScene PolicePhotos 20
Month Day Year Vehicles ..................................
Reconstructed Yes No
9 25 2020 FRIDAY 16 : 00 1 10
. VEHICLE 2 E BICYCLIST ¤ PEDESTRIAN
-2
VEHICLE1-Driver
LicenseIDNumber
VEHICLE 1
Stateof Lic. VEHICLE2- Driver
LicenseIDNumber
OTHER PEDESTRIAN
Stateof Llc,
DriverName-exactly DriverName- exactly _
as printedonIlconse
AddressrncludeNumber& Street)
aspnntedonlicense GOLDSTEIN,
Apt No. Address(/ncludeNumber& Street)
JENNIFER, Z
Apt.No. -
280 BAYBERRY DR
CityorTown State ZipCode CityorTown State ZIPCode
-
HEWLETT NY 11557
3 a Sex Unlicensed No.of Public D of irth Sex UnlIcensed No.of Public
Month Day Year Occupants Property Month Day Year Occupants Property
2 Damaged 6 9 1992 F 1 Damaged
Name-exactly asprintedonregistration Sex Name-exactlyasprintedonregistration Sex
Address(IncludeNumber& Street) Apt.No. Haz. sed Address(/ncludeNumber& Street) Apt No. Haz. Î Released 23
4 Mat Mat. X
1 GÁde Cod,
CityorTown State ZipCode CityorTown State Zip Code
24
PlateNumber Stateof Reg. VehicleYear& Make VehicleType Ins.Code PlateNumber tateofReg.VehicleYear& Make VehicleType ns.Code
7
BIKE
Ticket/Arrest Ticket/Arrest
- Number(s)
Violation
Number(s)
Violation
Section(s) SectIon(s)
25
Check if involved vehicle is: Check if involved vehicle is: Circle the diagram below that describes the accident, or draw your own -
6 more than 95 inches wide; ¤more than 95 inches wide; diagram in space #9. Number the vehicles.
V more than 34 feet long; V Omore than 34 feet long;
1
- E
H
operated with an overweight permit;
operated with an overdimensionpermit
E
H
Ooperated with an overweight permit;
¤°Perated with an overdimensionpermit.
RearEnd
-- --
Left Tum
3.
RightAngle RightTum HeadOn
...µ +
5, 7.
7
g VEHICLE 1 DAMAGE CODES
C Box 1 - Point of Impact 1 2
I
C
VEHICLE 2 DAMAGE CODES
Box 1 - Point of Impact 1 2
Sideswipe
(samedirection)
LeftTurn
+ RightTurn Sideswlpe
(oppoulte
-
26
1
L Box 2 - Most Damage L Box 2 - Most Damage 19 19 2. Ä- a. 4. e. ?' e. -p-
1 E
E Enter up to three 3 4 5 Enter up to three 3 4 5 ACCIDENT DIAGRAM
more Damage Codes more Damage Codes
2
Vehicle By Vehicle By 1
Towed. Towed:
To To
DIAGRAM ATTACHED ON SUBSEQUENT PAGE
VEHICLE DAMAGE CODING: y
1-13. SEE DIAGRAM ON RIGHT. 9 OTHER
14. UNDERCARRIAGE 17. DEMOLISHED 2 a
15. TRAILER 18. NO DAMAGE 9. 28
16. OVERTURNED 19. OTHER Cost of repairs to any one Vehicle will be more than $1000. 3
c Unknown/Unable to Determine Yes No
ReferenceMarker Coordinates (if available) Place Where Accident Occurred: BRONX¡KINGS ¡ NEW YORK¡ QUEENS ¤ RICHMOND
Latitude/Northing: Road on which accidentoccurred SAINT JOHNS PLACE
40.670116 (RouteNumberorStreetName) 29
at 1) intersectingstreet RALPH AVENUE
Longitude/Easting: (RouteNumberorStreetName)
N O S
-73 .92248 or2)
Miles
OE Ow of
(MilepostNearestIntersectino
RouteNumber
orStreetName)
FeSt
Accident Description/Officer'sNotes AT TPO BICYCLISTS STATES UNK VEHICLE DID HIT HER WHILE SHE WAS 30
TRAVELING WB ON ST JOHNS PL IN THE BIKE LANE.. CYCLISTS STATES SHES UNSURE OF LOCATION 1
VEHICLE CAME FROM. NO WITNESSES ON SCENE. NOT WITNESSED BY PD.
8 9 10 11 12 13 14 15 16 17 BY TO 14 N m gÁf ||involvgg Date of Deathtmly
A A 2B 1 1 1 28 F 1 12 6 - 7103 GOLDSTEIN, JENNIFER, Z
N
O
E
D
Officer's Rank Tax ID No, NCIC No. Precinct Post/Sector Reviewing Date/Time Reviewed
and Officer
Signature ) POM o9/2s/2020 14:31
953453 03030 073 SGT JIMMY WU
Print Name
in Full MATTHEW J STRZELCZYK
FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024
PERSONS KILLED OR INJURED IN ACCIDENT (Letter designation of persons killed or injufed must correspond with letter designation on front).
A Last Name First M.I. Last Name First M.L
GOLDSTEIN JENNIFER Z
Address Address
28 O BAYBERRY DR HEWLETT NY 11557
Date of Birth Telephone(Area Code) i Telephone(Area Code)
Month Day Year Month Day Year
Last Name First M.I. Last Name First M.I.
Address Address
Date of Birth Telephone(Area Code) Telephone(Area Code)
Month Day Year Month Day Year
Last Name First M.I.
Highway Dist. at Scene? ¤Yes¡No
Name:
Address
Date of Both Telephone(Area Code) Shield No.
Month Day Year
ENTER INSURANCE POLICY NUMBER FROM INSURANCE IDENTIFICATION CARD, EXPIRATION DATE (IN ALL CASES), AND VIN,
Vehicle No. 1 Vehicle No.2
Expiration Date Expiration Date
VIN VIN
WITNESS (Attach separate sheet, if necessary)
Name Add ess Phone
DUPLICATE COPY REQUIRED FOR:
¡ Dept. of Motor Vehicles ¡ Motor Transport Division O NYC Taxi & Limousine Comm. ¡ Other City Agency
(if anyone is killed/injured) (P.D. vehicle involved) (if a Licensed taxi or limousine (Specify)
involved)
Office of Comptroller ¡ Personnel Safety Unit ¡ Highway Unit
(if a City vehicle involved) (if a P.D. vehicle involved)
NOTIFICATIONS: (Enter name, address, and relationship of friend or relative notified. If aided person is unidentified, list Missing Person Squad member who
was notified. In either case, give date and time of notification.)
PROPERTY DAMAGED (other than vehicles) OWNER OF PROPERTY (include city agency, where applicable)
IF NYPD VEHICLE IS INVOLVED:
Police Vehicle -Operator's First Name Last Name Rank Shield No. Tax ID. No. Command
Make of Vehicle Year Type of Vehicle Plate No. Dept. Vehicle No. Assigned To What Command
Equipmentin Use At Time of Accident
¡ Siren ¡ Horn ¡ Turret Light O 4-Way Flasher ¡ High-Level Warning Lights ¡ Traffic Cones O Headlights
ACTIONS OF POLICE VEHICLE
O Responding to Code Signal ¤ Complying with Station House Directive
Pursuing Violator ¡ Routine Patrol
Other (Describe)
MV-104AN
(7/11) Page 2 of 2 Pages
FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024
Other : MV-2020-073-001335
Reporting Officer : POM MATTHEW J STRZELCZYK
Reviewing Officer : SGT JIMMY WU Reviewed Date : 09/26/2020 14:31
Document Filed Date
January 18, 2024
Case Filing Date
September 05, 2023
Category
Special Proceedings - CPLR Article 75
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024 Exhibit “A” FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024 Page1 of 2 Pages NewYork State Departmentof Motor Vehicles Precinct POLICE ACCIDENT REPORT (NYC) 19 073 MV-104AN (7/11) 13 AccidentNo. Complaint MV-2020-073 -001335 Number ¡ AMENDED REPORT DayofWeek MIlltaryTime No.of No.Injured No.Killed NotInvestigated atScene LeftScene PolicePhotos 20 Month Day Year Vehicles .................................. Reconstructed Yes No 9 25 2020 FRIDAY 16 : 00 1 10 . VEHICLE 2 E BICYCLIST ¤ PEDESTRIAN -2 VEHICLE1-Driver LicenseIDNumber VEHICLE 1 Stateof Lic. VEHICLE2- Driver LicenseIDNumber OTHER PEDESTRIAN Stateof Llc, DriverName-exactly DriverName- exactly _ as printedonIlconse AddressrncludeNumber& Street) aspnntedonlicense GOLDSTEIN, Apt No. Address(/ncludeNumber& Street) JENNIFER, Z Apt.No. - 280 BAYBERRY DR CityorTown State ZipCode CityorTown State ZIPCode - HEWLETT NY 11557 3 a Sex Unlicensed No.of Public D of irth Sex UnlIcensed No.of Public Month Day Year Occupants Property Month Day Year Occupants Property 2 Damaged 6 9 1992 F 1 Damaged Name-exactly asprintedonregistration Sex Name-exactlyasprintedonregistration Sex Address(IncludeNumber& Street) Apt.No. Haz. sed Address(/ncludeNumber& Street) Apt No. Haz. Î Released 23 4 Mat Mat. X 1 GÁde Cod, CityorTown State ZipCode CityorTown State Zip Code 24 PlateNumber Stateof Reg. VehicleYear& Make VehicleType Ins.Code PlateNumber tateofReg.VehicleYear& Make VehicleType ns.Code 7 BIKE Ticket/Arrest Ticket/Arrest - Number(s) Violation Number(s) Violation Section(s) SectIon(s) 25 Check if involved vehicle is: Check if involved vehicle is: Circle the diagram below that describes the accident, or draw your own - 6 more than 95 inches wide; ¤more than 95 inches wide; diagram in space #9. Number the vehicles. V more than 34 feet long; V Omore than 34 feet long; 1 - E H operated with an overweight permit; operated with an overdimensionpermit E H Ooperated with an overweight permit; ¤°Perated with an overdimensionpermit. RearEnd -- -- Left Tum 3. RightAngle RightTum HeadOn ...µ + 5, 7. 7 g VEHICLE 1 DAMAGE CODES C Box 1 - Point of Impact 1 2 I C VEHICLE 2 DAMAGE CODES Box 1 - Point of Impact 1 2 Sideswipe (samedirection) LeftTurn + RightTurn Sideswlpe (oppoulte - 26 1 L Box 2 - Most Damage L Box 2 - Most Damage 19 19 2. Ä- a. 4. e. ?' e. -p- 1 E E Enter up to three 3 4 5 Enter up to three 3 4 5 ACCIDENT DIAGRAM more Damage Codes more Damage Codes 2 Vehicle By Vehicle By 1 Towed. Towed: To To DIAGRAM ATTACHED ON SUBSEQUENT PAGE VEHICLE DAMAGE CODING: y 1-13. SEE DIAGRAM ON RIGHT. 9 OTHER 14. UNDERCARRIAGE 17. DEMOLISHED 2 a 15. TRAILER 18. NO DAMAGE 9. 28 16. OVERTURNED 19. OTHER Cost of repairs to any one Vehicle will be more than $1000. 3 c Unknown/Unable to Determine Yes No ReferenceMarker Coordinates (if available) Place Where Accident Occurred: BRONX¡KINGS ¡ NEW YORK¡ QUEENS ¤ RICHMOND Latitude/Northing: Road on which accidentoccurred SAINT JOHNS PLACE 40.670116 (RouteNumberorStreetName) 29 at 1) intersectingstreet RALPH AVENUE Longitude/Easting: (RouteNumberorStreetName) N O S -73 .92248 or2) Miles OE Ow of (MilepostNearestIntersectino RouteNumber orStreetName) FeSt Accident Description/Officer'sNotes AT TPO BICYCLISTS STATES UNK VEHICLE DID HIT HER WHILE SHE WAS 30 TRAVELING WB ON ST JOHNS PL IN THE BIKE LANE.. CYCLISTS STATES SHES UNSURE OF LOCATION 1 VEHICLE CAME FROM. NO WITNESSES ON SCENE. NOT WITNESSED BY PD. 8 9 10 11 12 13 14 15 16 17 BY TO 14 N m gÁf ||involvgg Date of Deathtmly A A 2B 1 1 1 28 F 1 12 6 - 7103 GOLDSTEIN, JENNIFER, Z N O E D Officer's Rank Tax ID No, NCIC No. Precinct Post/Sector Reviewing Date/Time Reviewed and Officer Signature ) POM o9/2s/2020 14:31 953453 03030 073 SGT JIMMY WU Print Name in Full MATTHEW J STRZELCZYK FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024 PERSONS KILLED OR INJURED IN ACCIDENT (Letter designation of persons killed or injufed must correspond with letter designation on front). A Last Name First M.I. Last Name First M.L GOLDSTEIN JENNIFER Z Address Address 28 O BAYBERRY DR HEWLETT NY 11557 Date of Birth Telephone(Area Code) i Telephone(Area Code) Month Day Year Month Day Year Last Name First M.I. Last Name First M.I. Address Address Date of Birth Telephone(Area Code) Telephone(Area Code) Month Day Year Month Day Year Last Name First M.I. Highway Dist. at Scene? ¤Yes¡No Name: Address Date of Both Telephone(Area Code) Shield No. Month Day Year ENTER INSURANCE POLICY NUMBER FROM INSURANCE IDENTIFICATION CARD, EXPIRATION DATE (IN ALL CASES), AND VIN, Vehicle No. 1 Vehicle No.2 Expiration Date Expiration Date VIN VIN WITNESS (Attach separate sheet, if necessary) Name Add ess Phone DUPLICATE COPY REQUIRED FOR: ¡ Dept. of Motor Vehicles ¡ Motor Transport Division O NYC Taxi & Limousine Comm. ¡ Other City Agency (if anyone is killed/injured) (P.D. vehicle involved) (if a Licensed taxi or limousine (Specify) involved) Office of Comptroller ¡ Personnel Safety Unit ¡ Highway Unit (if a City vehicle involved) (if a P.D. vehicle involved) NOTIFICATIONS: (Enter name, address, and relationship of friend or relative notified. If aided person is unidentified, list Missing Person Squad member who was notified. In either case, give date and time of notification.) PROPERTY DAMAGED (other than vehicles) OWNER OF PROPERTY (include city agency, where applicable) IF NYPD VEHICLE IS INVOLVED: Police Vehicle -Operator's First Name Last Name Rank Shield No. Tax ID. No. Command Make of Vehicle Year Type of Vehicle Plate No. Dept. Vehicle No. Assigned To What Command Equipmentin Use At Time of Accident ¡ Siren ¡ Horn ¡ Turret Light O 4-Way Flasher ¡ High-Level Warning Lights ¡ Traffic Cones O Headlights ACTIONS OF POLICE VEHICLE O Responding to Code Signal ¤ Complying with Station House Directive Pursuing Violator ¡ Routine Patrol Other (Describe) MV-104AN (7/11) Page 2 of 2 Pages FILED: NASSAU COUNTY CLERK 01/18/2024 02:30 PM INDEX NO. 614356/2023 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 01/18/2024 Other : MV-2020-073-001335 Reporting Officer : POM MATTHEW J STRZELCZYK Reviewing Officer : SGT JIMMY WU Reviewed Date : 09/26/2020 14:31