Miscellaneous: Government Employee Insurance Company Subrogee of Margarida Mello vs. Essex County Sheriff

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                                Date Filed 6/19/2024 9:50 AM
Superior Court - Essex
Docket Number.


                                                                                                                                                                        x
                                                                               DOCKET NUMBER                            Trial Court of Massachusetts                        accent
                                                                                                                                                                                ees
            CIVIL ACTION COVER SHEET                                          2417 cvooel                     ] -bd The Superior Court
     PLAINTIFF(S):            Government Employee Insurance Company als/o Marina Boskovicy                              COUNTY

    ADDRESS:                  .T Corporation System, 155 Federal St, Ste 700 Boston MA 02110                                         Essex

                                                                                                 DEFENDANT(S):       ESSEX COUNTRY SHERIFF


    ATTORNEY:                 Paul Daly
    ADDRESS:                  29 Crafts St, Ste 360 Newton MA 02458                              ADDRESS:           20 Manning Ave Middleton MA 01949




    BEO:                      695762
                                                            TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
                 CODE NO.                              TYPE OF ACTION (specify)                  CK             HAS A JURY CLAIM BEEN MADE?
           ab1                               Tort Action Involving Commonwealth               A                             (no      &] yes
       *If "Other" please describe:

                  Is there a claim under G.L. c. 93A?                                                        Is this a class action under Mass. R. Civ. P. 23?
                       YES:
                                                                 STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, § 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.
    For this form, disregard double or treble damage claims; indicate single damages only.
                                                                                               ‘ORT CLAIMS
                                                                                 (attach additional sheets as necessary)
    A. Documented medical expenses to date:
              1. Total hospital expenses:
                 2.   Total   doctor expenses
                 3.   Total   chiropractic expenses
                 4.   Total   physical therapy exper
                 5.   Total   other expenses (describe below)
                                                                                                                                                    Subtotal (A):
      Insurance Benefits paid.
    |B. Documented lost wages and compensation to date ....
    C. Documented property damages to date . .
    ID. Reasonably anticipated future medical and hospital expenses
    IE. Reasonably anticipated lost wages . .
    F. Other documented items of damages (describe below) .                                                                                                            525

    |G. Briefly describe plaintiff's injury, including the nature and extent of injury:

                                                                                                                                                        TOTAL (A-F):$1,524.85



                                                                                       col          CLAIM:
                                                                              (attach additional sheets as necessary)
      J This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a).
    Provide a detailed description of claim(s):
                                                                                                                                                            TOTAL: $


     Signature of Attorney/ Unrepresented Plaintiff: X                                                                                                    Date:
    RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court.


                                                                      CERTIFICATION PURSUANT TO SJC RULE 1:18
    | hereby certify that | have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SJC
    Rule 1:18) requiring that | provide my clients with information about court-connected dispute resolution services and discuss with them the
    advantages and disadvantages of the various methods of dispute resolution.

    ‘Signature of Attorney of Record:                   X              /s/ Paul Daly                                                                      Date:   Jun 18, 2024