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Date Filed 4/11/2024 2:11 PM
Su rior Court - Norfolk. 2
Docket Number DOCKET NUMBER Massachusetts Trial Court
CIVIL ACTION COVER SHEET 2482cv00354 Superior Court ce
[COUNTY] Norfolk Superior Court (Dedham)
Plaintiff ‘Amica Mutual Insurance Company as subrogee of Defendant: Devaney Energy Inc.
Jeanne Lukanich
ADDRESS: 100 Amica Way ADDRESS: 177 Wells Ave, Newton, MA 02459
Lincoln, Rhode Island 02865
Plaintiff Attorney: Michael S. Antonellis Defendant Attorney:
ADDRESS: Sloane and Walsh LLP ADDRESS:
201 Washington Street, 16th Floor
Boston, MA 02108
BBO: 600501 BBO:
TYPE OF ACTION AND TRACK DESIGNATION (see instructions section on next page)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
BOo4 Other Negligence/Property Damage F &] Yes no
*If "Other" please describe: Property Damage
Is there a claim under G.L. c. 933A? Is there a class action under Mass. R. Civ. P. 23?
Oo yes [I No (yes [No
STATEMENT OF DAMAGES REQUIRED BY 12, § 3A
The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money damages.
(Note to plaintiff: for this form, do not state double or treble damages; indicate single damages only.)
|A. Documented medical expenses to date
1. Total hospital expenses
2. Total doctor expenses
3. Total chiropractic expenses
4. Total physical therapy expenses
5, Total other expenses (describe below)
Subtotal (1-5). $0.00
B. Documented lost wages and compensation to date
C. Documented property damages to date $423,968.77
D. Reasonably anticipated future medical and hospital expenses
E, Reasonably anticipated lost wages
F. Other documented items of damages (describe below)
|
TOTAL (A-F): $423,968.77
G. Briefly describe plaintif’s injury, including the nature and extent of the injury:
CONTRACT CLAIMS
[11 This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a).
Item # Detailed Description of Each Claim Amount
1
Total
Signature of Attorney/Self-Represented Plaintiff: X_/s/ Michael S. Antonelllis | | Date: 4111124
RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court.
CERTIFICATION UNDER S.J.C. RULE 1:18(5)
hereby certify that | have complied with requirements of Rule 5 of Supreme Judicial Court Rule 1:18: Uniform Rules on Dispute Resolution, requiring that | inform my clients about
court-connected dispute resolution services and discuss with them the advantages and disadvantages of the various methods of dispute resolution.
Signature of Attorney: X /s/ Michael S. Antonellis [Date: 4111124
$C0001: 02/24 www.mass.govicourts Date/Time Printed:04-10-2024 10:33:34
Date Filed 4/11/2024 2:11 PM
Superior Court - Norfolk
Docket Number CIVIL ACTION COVER SHEET INSTRUCTIONS —
SELECT A CATEGORY THAT BEST DESCRIBES YOUR CASE*
AC Actions Involving the State/Municipality ER Equitable Remedies RP Real Property
AA‘ Contract Action involving Commonwealth, DO1 Specific Performance of a Contract (A) C01 Land Taking (F)
Municipality, MBTA, etc. D02 Reach and Apply ) C02 Zoning Appeal, G.L. c. 40 (F)
AB1 Tortious Action involving Commonwealth, 1DO3 Injunction (F) C03 Dispute Concerning Title (F)
Municipality, MBTA, etc. (A) 104 Reform/ Cancel Instrument ) C04 Foreclosure of a Mortgage )
AC1 Real Property Action involving DOS Equitable Replevin (F) C05 Condominium Lien & Charges (x)
Commonwealth, Municipality, MBTA etc. (A) 106 Contribution or indemnification F) C99 Other Real Property Action (F)
AD1 Equity Action involving Commonwealth, DO7 Imposition of a Trust (A)
Municipality, MBTA, etc. (A) 08 Minority Shareholder's Suit (A) -MC
Miscellaneous
Civil Actions
AE1 Administrative Action involving D09 Interference in Contractual Relationship (F)
Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting E18 Foreign Discovery Proceeding )
D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus.
CN
Contract/Business
Cases D12 Dissolution of a Partnership F) E22 Lottery Assignment, G.L. c. 10, § 28
D13 Declaratory Judgment, G.L. c. 231A (A)
A01 Services, Labor, and Materials (F) D14 Dissolution of a Corporation (F) AB Abuse/Harassment Prevention
A02 Goods Sold and Delivered (F) 1D99 Other Equity Action (F)
‘A03 Commercial Paper (F) E15 Abuse Prevention Petition, G.L.c. 209A _(X)
‘A04 Employment Contract (F) PA Givil Actions Involving Incarcerated
Party * E21 Protection from Harassment, G.L. c. 258E(X)
A05 Consumer Revolving Credit - mRoP. 6.1 (F)
A06 Insurance Contract (F) PA1 Contract Action involving an _AA
Administrative
Civil Actions
A08 Sale or Lease of Real Estate (F) Incarcerated Party (a)
‘12 Construction Dispute (A) PB1 Tortious Action involving an E02 Appeal from Administrative Agency,
A14 Interpleader (F) Incarcerated Party (a) GL.c. 3 )
BA1 Governance, Conduct, Internal PC1 Real Property Action involving an E03 Certiorari Action, G.L. c. 249, § 4 (x)
Affairs of Entities (A) Incarcerated Party ) E05 Confirmation of Arbitration Awards )
BA3 Liability of Shareholders, Directors, PD1 Equity Action involving an E06 Mass Antitrust Act, G.L. c. 93, § 9 (A)
Officers, Partners, etc. (A) Incarcerated Party ) E07 Mass Antitrust Act, G.L. c. 93, § 8 )
BB1 Shareholder Derivative (A) PE1 Administrative Action involving an E08 Appointment of a Receiver (x)
BB2 Securities Transactions (A) Incarcerated Party ) E09 Construction Surety Bond, G.L. ¢. 149,
BC1 Mergers, Consolidations, Sales of §§ 29, 29A (A)
Assets, Issuance of Debt, Equity, etc. (A) TR Torts E10 Summary Process Appeal )
BD1 Intellectual Property (A) E11 Worker's Compensation (x)
BD2 Proprietary Information or Trade B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal )
Secrets (A) Injury/Property Damage (F) E17 Civil Rights Act, G.L. ¢.12, § 11H (A)
BG1 Financial Institutions/Funds (A) B04 Other Negligence - Personal E24 Appeal from District Court
BH1 Violation of Antitrust or Trade Injury/Property Damage (F) Commitment, G.L. 6.123, § 9(b) (x)
Regulation Laws (A) B05 Products Liability (a) E94 Forfeiture, G.L. c. 265, § 56 )
‘A99 Other Contract/Business Action - Specify (F) B06 Malpractice - Medical (A) E95 Forfeiture, G.L. c. 94C, § 47 (F)
BO7 Malpractice - Other (a) E99 Other Administrative Action )
* See Superior Court Standing Order 1-88 for an B08 Wrongful Death - Non-medical (a) 201 Medical Malpractice - Tribunal only,
‘explanation of the tracking deadlines for each track B15 Defamation (A) GL. c. 231, § 60B (F)
designation: F, A, and X. On this page, the track B19 Asbestos (A) 202 Appeal Bond Denial )
designation for each case type is noted in B20 Personal Injury - Slip & Fall (F)
parentheses. B21 Environmental (F) ‘SO Sex Offender Review
B22 Employment Discrimination (F)
+* Choose this case type if ANY party is the BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. c. 123A, § 12 )
‘Commonwealth, a municipality, the MBTA, or any B99 Other Tortious Action (F) E14 SDP Petition, G.L. c. 123A, § 9(b) (x)
other governmental entity UNLESS your case is a
case type listed under Administrative Civil Actions RP Summary Process (Real Property) RC
Restricted
Givil Actions
(AA).
801 Summary Process - Residential (x) E19 Sex Offender Registry, G.L. c. 6, § 178M (X)
Choose this case type if ANY party is an $02 Summary Process - Commercial/ E27 Minor Seeking Consent, G.L. ¢.112, § 128(X)
incarcerated party, UNLESS your case is a case Non-residential (F)
type listed under Administrative Civil Actions (AA)
oris a Prisoner Habeas Corpus case (E97). TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
BO. Motor Vehicle Negligence-Personal Injury —f. KI Yes (no
STATEMENT OF DAMAGES REQUIRED BY G.L. c. 212, § 3A
DUTY OF THE PLAINTIFF — On the face of the Civil Action Cover Sheet (or on attached additional sheets, if necessary), the plaintiff shall
state the facts on which the plaintiff relies to determine money damages. A copy of the completed Civil Action Cover Sheet, including the
statement conceming damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, except as
otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant.
DUTY OF THE DEFENDANT — If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may
file with the defendant's answer a statement specifying the potential damages which may result if the plaintiff prevails.
A CIVIL ACTION COVER SHEET MUST BE FILED WITH EACH COMPLAINT.
IF THIS COVER SHEET IS NOT FILLED OUT THOROUGHLY AND
ACCURATELY, THE CASE MAY BE DISMISSED.
$C0001: 02/24 www.mass.gov/courts Date/Time Printed:04-10-2024 10:33:34
Preview
Date Filed 4/11/2024 2:11 PM Su rior Court - Norfolk. 2 Docket Number DOCKET NUMBER Massachusetts Trial Court CIVIL ACTION COVER SHEET 2482cv00354 Superior Court ce [COUNTY] Norfolk Superior Court (Dedham) Plaintiff ‘Amica Mutual Insurance Company as subrogee of Defendant: Devaney Energy Inc. Jeanne Lukanich ADDRESS: 100 Amica Way ADDRESS: 177 Wells Ave, Newton, MA 02459 Lincoln, Rhode Island 02865 Plaintiff Attorney: Michael S. Antonellis Defendant Attorney: ADDRESS: Sloane and Walsh LLP ADDRESS: 201 Washington Street, 16th Floor Boston, MA 02108 BBO: 600501 BBO: TYPE OF ACTION AND TRACK DESIGNATION (see instructions section on next page) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? BOo4 Other Negligence/Property Damage F &] Yes no *If "Other" please describe: Property Damage Is there a claim under G.L. c. 933A? Is there a class action under Mass. R. Civ. P. 23? Oo yes [I No (yes [No STATEMENT OF DAMAGES REQUIRED BY 12, § 3A The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money damages. (Note to plaintiff: for this form, do not state double or treble damages; indicate single damages only.) |A. Documented medical expenses to date 1. Total hospital expenses 2. Total doctor expenses 3. Total chiropractic expenses 4. Total physical therapy expenses 5, Total other expenses (describe below) Subtotal (1-5). $0.00 B. Documented lost wages and compensation to date C. Documented property damages to date $423,968.77 D. Reasonably anticipated future medical and hospital expenses E, Reasonably anticipated lost wages F. Other documented items of damages (describe below) | TOTAL (A-F): $423,968.77 G. Briefly describe plaintif’s injury, including the nature and extent of the injury: CONTRACT CLAIMS [11 This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a). Item # Detailed Description of Each Claim Amount 1 Total Signature of Attorney/Self-Represented Plaintiff: X_/s/ Michael S. Antonelllis | | Date: 4111124 RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court. CERTIFICATION UNDER S.J.C. RULE 1:18(5) hereby certify that | have complied with requirements of Rule 5 of Supreme Judicial Court Rule 1:18: Uniform Rules on Dispute Resolution, requiring that | inform my clients about court-connected dispute resolution services and discuss with them the advantages and disadvantages of the various methods of dispute resolution. Signature of Attorney: X /s/ Michael S. Antonellis [Date: 4111124 $C0001: 02/24 www.mass.govicourts Date/Time Printed:04-10-2024 10:33:34 Date Filed 4/11/2024 2:11 PM Superior Court - Norfolk Docket Number CIVIL ACTION COVER SHEET INSTRUCTIONS — SELECT A CATEGORY THAT BEST DESCRIBES YOUR CASE* AC Actions Involving the State/Municipality ER Equitable Remedies RP Real Property AA‘ Contract Action involving Commonwealth, DO1 Specific Performance of a Contract (A) C01 Land Taking (F) Municipality, MBTA, etc. D02 Reach and Apply ) C02 Zoning Appeal, G.L. c. 40 (F) AB1 Tortious Action involving Commonwealth, 1DO3 Injunction (F) C03 Dispute Concerning Title (F) Municipality, MBTA, etc. (A) 104 Reform/ Cancel Instrument ) C04 Foreclosure of a Mortgage ) AC1 Real Property Action involving DOS Equitable Replevin (F) C05 Condominium Lien & Charges (x) Commonwealth, Municipality, MBTA etc. (A) 106 Contribution or indemnification F) C99 Other Real Property Action (F) AD1 Equity Action involving Commonwealth, DO7 Imposition of a Trust (A) Municipality, MBTA, etc. (A) 08 Minority Shareholder's Suit (A) -MC Miscellaneous Civil Actions AE1 Administrative Action involving D09 Interference in Contractual Relationship (F) Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting E18 Foreign Discovery Proceeding ) D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus. CN Contract/Business Cases D12 Dissolution of a Partnership F) E22 Lottery Assignment, G.L. c. 10, § 28 D13 Declaratory Judgment, G.L. c. 231A (A) A01 Services, Labor, and Materials (F) D14 Dissolution of a Corporation (F) AB Abuse/Harassment Prevention A02 Goods Sold and Delivered (F) 1D99 Other Equity Action (F) ‘A03 Commercial Paper (F) E15 Abuse Prevention Petition, G.L.c. 209A _(X) ‘A04 Employment Contract (F) PA Givil Actions Involving Incarcerated Party * E21 Protection from Harassment, G.L. c. 258E(X) A05 Consumer Revolving Credit - mRoP. 6.1 (F) A06 Insurance Contract (F) PA1 Contract Action involving an _AA Administrative Civil Actions A08 Sale or Lease of Real Estate (F) Incarcerated Party (a) ‘12 Construction Dispute (A) PB1 Tortious Action involving an E02 Appeal from Administrative Agency, A14 Interpleader (F) Incarcerated Party (a) GL.c. 3 ) BA1 Governance, Conduct, Internal PC1 Real Property Action involving an E03 Certiorari Action, G.L. c. 249, § 4 (x) Affairs of Entities (A) Incarcerated Party ) E05 Confirmation of Arbitration Awards ) BA3 Liability of Shareholders, Directors, PD1 Equity Action involving an E06 Mass Antitrust Act, G.L. c. 93, § 9 (A) Officers, Partners, etc. (A) Incarcerated Party ) E07 Mass Antitrust Act, G.L. c. 93, § 8 ) BB1 Shareholder Derivative (A) PE1 Administrative Action involving an E08 Appointment of a Receiver (x) BB2 Securities Transactions (A) Incarcerated Party ) E09 Construction Surety Bond, G.L. ¢. 149, BC1 Mergers, Consolidations, Sales of §§ 29, 29A (A) Assets, Issuance of Debt, Equity, etc. (A) TR Torts E10 Summary Process Appeal ) BD1 Intellectual Property (A) E11 Worker's Compensation (x) BD2 Proprietary Information or Trade B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal ) Secrets (A) Injury/Property Damage (F) E17 Civil Rights Act, G.L. ¢.12, § 11H (A) BG1 Financial Institutions/Funds (A) B04 Other Negligence - Personal E24 Appeal from District Court BH1 Violation of Antitrust or Trade Injury/Property Damage (F) Commitment, G.L. 6.123, § 9(b) (x) Regulation Laws (A) B05 Products Liability (a) E94 Forfeiture, G.L. c. 265, § 56 ) ‘A99 Other Contract/Business Action - Specify (F) B06 Malpractice - Medical (A) E95 Forfeiture, G.L. c. 94C, § 47 (F) BO7 Malpractice - Other (a) E99 Other Administrative Action ) * See Superior Court Standing Order 1-88 for an B08 Wrongful Death - Non-medical (a) 201 Medical Malpractice - Tribunal only, ‘explanation of the tracking deadlines for each track B15 Defamation (A) GL. c. 231, § 60B (F) designation: F, A, and X. On this page, the track B19 Asbestos (A) 202 Appeal Bond Denial ) designation for each case type is noted in B20 Personal Injury - Slip & Fall (F) parentheses. B21 Environmental (F) ‘SO Sex Offender Review B22 Employment Discrimination (F) +* Choose this case type if ANY party is the BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. c. 123A, § 12 ) ‘Commonwealth, a municipality, the MBTA, or any B99 Other Tortious Action (F) E14 SDP Petition, G.L. c. 123A, § 9(b) (x) other governmental entity UNLESS your case is a case type listed under Administrative Civil Actions RP Summary Process (Real Property) RC Restricted Givil Actions (AA). 801 Summary Process - Residential (x) E19 Sex Offender Registry, G.L. c. 6, § 178M (X) Choose this case type if ANY party is an $02 Summary Process - Commercial/ E27 Minor Seeking Consent, G.L. ¢.112, § 128(X) incarcerated party, UNLESS your case is a case Non-residential (F) type listed under Administrative Civil Actions (AA) oris a Prisoner Habeas Corpus case (E97). TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? BO. Motor Vehicle Negligence-Personal Injury —f. KI Yes (no STATEMENT OF DAMAGES REQUIRED BY G.L. c. 212, § 3A DUTY OF THE PLAINTIFF — On the face of the Civil Action Cover Sheet (or on attached additional sheets, if necessary), the plaintiff shall state the facts on which the plaintiff relies to determine money damages. A copy of the completed Civil Action Cover Sheet, including the statement conceming damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, except as otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant. DUTY OF THE DEFENDANT — If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may file with the defendant's answer a statement specifying the potential damages which may result if the plaintiff prevails. A CIVIL ACTION COVER SHEET MUST BE FILED WITH EACH COMPLAINT. IF THIS COVER SHEET IS NOT FILLED OUT THOROUGHLY AND ACCURATELY, THE CASE MAY BE DISMISSED. $C0001: 02/24 www.mass.gov/courts Date/Time Printed:04-10-2024 10:33:34