Preview
FILED: KINGS COUNTY CLERK 06/20/2024 05:18 PM INDEX NO. 514224/2024
NYSCEF DOC. NO. 8 RECEIVED NYSCEF: 06/20/2024
6
The City of New York
MURIEL GOODE-TRUFANT LAW DEPARTMENT
Acting Corporation Counsel 100 CHURCH STREET
NEW YORK, NEW YORK 10007
Dear Counsel:
If you would like to have this case considered for possible early settlement by the
Early Intervention Unit of the Tort Division, the following items (as applicable) should be
forwarded to the attention of Olivia Lam via email to olam@law.nyc.gov.
IN ALL CASES COPIES OF THE FOLLOWING ITEMS MUST BE PROVIDED:
1. Notice of Claim and Filed Summons & Complaint.
2. Aided Card, if prepared.
3. UF18 - City Involved Accident Report, if prepared.
4. All medical and hospital records, including ambulance call report, first treatment, full
emergency room record, operative and radiology reports, treating physician(s) reports,
physical therapy records, etc.
5. Photographs (duplicates, color or laser copies preferred) of the location and of injuries, if
scarring is claimed.
6. Proof of any special damages claimed.
7. Any other item(s) that you believe pertinent to an early resolution of your case.
8. Social Security number and any other Medicare information – see attached notice
ALLEGED TRIP AND FALL ON A SIDEWALK OR ROADWAY
1. Most recently dated Big Apple map.
2. Any other documents that the plaintiff will rely upon to prove prior written notice.
MOTOR VEHICLE ACCIDENT CASES
1. Police Accident Report.
2. Agency incident/accident report, if prepared.
3. Repair bills and/or estimates.
4. If the accident involves traffic light or stop sign, any documentation that the plaintiff will
rely upon to prove notice.
ALLEGED PREMISES LIABILITY
1. Copies of any documents that plaintiff will rely on to establish ownership of the premises.
2. Prior complaints.
3. Accident/incident reports.
DEPARTMENT OF EDUCATION CASES
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1. Accident and/or incident report and attachments, if any.
2. Custodian reports.
3. Teacher(s) statements/reports.
4. Witness statements.
ALLEGED POLICE MISCONDUCT
1. Any police reports in your possession.
2. Arrest Report, Complaint report, follow-up reports and photographs.
3. Certified copy of the disposition of any criminal proceedings.
4. If entitlement to reimbursement of legal fees is claimed, copies of any bills incurred.
ALLEGED PROPERTY DAMAGE
1. Photographs (duplicates, color or laser copies preferred) depicting the items alleged to have
been damaged, prior and subsequent to the damage.
2. Original purchase receipts, cancelled checks, and/or charge slips for the items alleged to
have been damaged.
3. Appraisals, warranties, etc.
4. Copies of any insurance agreements pertaining to property damages and/or loss.
Please be advised that all of the above materials must be sent in order to have your case considered
for possible early settlement - incomplete cases cannot be considered. Within 30 days after receipt
of the above materials via email, you will be contacted to discuss the case further. Counsel
appearing at the conference must have settlement authority and be prepared to establish liability
and damages. If you have any questions, you may contact Nancy A. Goldbach directly by email to
ngoldbac@law.nyc.gov.
Very truly yours,
Nancy A. Goldbach
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The City of New York
LAW DEPARTMENT
Office of the Corporation Counsel medicare@law.nyc.gov
Ethics and Compliance Division
MURIEL GOODE-TRUFANT Medicare Compliance and Recovery Unit
Acting Corporation Counsel 100 Church Street, 20th Floor
New York, NY 10007-2668
June 20, 2024
THE LAW OFFICE OF KATHERINE E. SMITH
233 Broadway, Suite 900
New York, NY 10279
Re: TYMERE JOHNSON v. CITY OF NEW YORK;
POLICE OFFICER DENNIS M. DIAZ (SHIELD
NO. 1270); NYPD OFFICERS JOHN and JANE
DOE 1 through 10, (the names John and Jane Doe
being fictitious, as the true names are presently
unknown)
Law Dept. File No: 2024-047735
Dear Counselor:
We write to request that you provide us with certain personal identifying information about
each plaintiff you represent in this lawsuit in order for us to determine whether they are a Medicare
recipient(s). Specifically, we need each plaintiff’s date of birth, gender, and Social Security
number or Health Insurance Claim Number (HICN), also known as the Medicare number. This
information will be used by the Law Department to obtain plaintiff’s Medicare status via a database
established by the Centers for Medicare & Medicaid Services ("CMS") for this purpose.1
Information about a plaintiff’s Medicare status is required by the City in order to comply
with federal Medicare laws. Self-insured liability entities (such as the City of New York) are
considered “primary plans” under the Medicare laws and are, therefore, required to report to CMS
all monetary recoveries obtained by Medicare-eligible plaintiffs in personal injury lawsuits. See
1CMS has developed a "query process" under which a responsible reporting entity (RRE) (such as the City in this
case) can determine a claimant's Medicare status electronically, as long as the RRE has access to the claimant's
name, date of birth, gender and social security number. Seger v. Tank Connection, LLC, 2010 U.S. Dist. LEXIS
49013 at *13 (D. Neb. Apr. 22, 2010).
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Medicare Secondary Payer Act (MSPA) 42 U.S.C. 1395y(b)(8)(A)(i); Seger v. Tank Connection,
LLC, 2010 U.S. Dist. LEXIS 49013 (D. Neb. Apr. 22, 2010) ) (“the Extension Act adds new
mandatory reporting obligations to the Medicare Secondary Payer Act ("MSPA") requiring . . .
self-insurers to provide detailed information regarding all liability settlements or open claims with
ongoing responsibility for medical treatment with Medicare beneficiaries to the Centers for
Medicare and Medicaid Services ("CMS")”). Torres v Visto Realty Corp., 2015 N.Y. App. Div.
LEXIS 3216, 1-2 (1st Dep't 2015) (“plaintiff did not satisfy his obligations under CPLR 5003-a,
since he failed to provide defendant with the information relating to his Medicare status that
defendant requires to comply with its reporting obligations under 42 USC § 1395y”) (citations
omitted); Bey v. City of New York, 2013 U.S. Dist. LEXIS 15597, at *5-6 (E.D.N.Y. Feb. 5, 2013)
(same.). Thus, the City needs to ascertain plaintiff’s Medicare status for the purposes of satisfying
its reporting obligations.
Additionally, the City also requires the personal identifying information to resolve any
outstanding Medicare claims before issuing payment on settlements. See MSPA, 42 U.S.C.
1395y(b)(2)(B)(ii) (“a primary plan’s responsibility for such payment may be demonstrated by a
judgment [or settlement] . . . for items or services included in a claim against the primary plan . .
. .”); see also Torres v. Hirsch Park, LLC, 91 AD.3d 942 (2nd Dep’t 2012) (“the authorizations that
the Supreme Court directed the plaintiff to provide are necessary for the defendant to comply with
its statutory duty to report the identity of a claimant who is entitled to Medicare benefits (see 42
USC 1395y[b][8]) and to determine the existence of potential subrogation claims [under federal
law]”) (citations omitted); Liss v. Brigham Park Coop Apts., 264 A.D.2d 717 (2d Dep’t 1999)
(because the Federal government has a right of action directly against the defendant for recovery
of its lien, it was “incumbent upon plaintiff to resolve the lien and give the defendant a release.”)
Indeed, the responsibility of assuring reimbursement of Medicare claims extends to all
entities involved in the underlying liability action, including the plaintiff’s counsel. CFR §
411.24(g); United States v. Harris, 2009 U.S. Dist. LEXIS 23956 (N.D. W. Va. Mar. 26, 2009)
(holding that plaintiff’s attorney is liable to Medicare for unpaid liens because he disbursed
settlement funds in a liability case to his client without first reimbursing Medicare for its claims).
Thus, it is to all parties’ benefit to ascertain a plaintiff’s Medicare status as early as possible so as
to resolve any existing Medicare claims and facilitate payment of settlements.
In view of the foregoing, we ask that you promptly submit to us the requested information.
If you know for a fact that your client presently receives Medicare, you should immediately (1)
notify Medicare of the pending lawsuit; 2 (2) provide the Law Department with plaintiff’s Medicare
identification number and/or social security number; (3) obtain conditional and final payment
information from Medicare and (4) provide copies of any correspondences to the City. If future
2 If you have never notified Medicare about this injury claim before, the first step is to report the injury to the Benefits
Coordination & Recovery Contractor (BCRC) at P.O. Box 138897, Oklahoma City, OK 73113-8897, or by telephone
at 1-855-798-2627. A case identifier will be established, and you will then receive a correspondence from the
BCRC concerning any conditional payments made by Medicare on your client’s behalf for the injuries underlying this
case. BCRC is the agency that will issue final demand letters on amounts due Medicare. More detailed information
concerning the foregoing procedures can be found at http://go.cms.gov/cobro by clicking on the links to the left of
the screen entitled 'Non-Group Health Plan Recovery' and 'Reimbursing Medicare'. There is also a portal on this
website, the Medicare Secondary Payer Recovery Portal (MSPRP) that allows registered users to access and update
certain case-specific information online, including an electronic conditional payment letter. Please visit the website
for information as how to register for this service.
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medical care for plaintiff is anticipated, you may also need to consider a Medicare set-aside
instrument for payment of future medical costs; 3
If plaintiff was insured under a Medicare Advantage Plan (“MAP”) under Part C of the
Medicare Act at any time after the incident at issue here, plaintiff should notify the City about the
MAP coverage, and also inform the MAP(s) of this lawsuit. Recent New York decisions have
held that a MAP provider can pursue recovery of its reimbursement and/or subrogation claims in
the same manner as traditional Medicare. See Potts v. Rawlings Co., LLC, 897 F. Supp. 2d 185
(S.D.N.Y. 2012); Trezza v Trezza, 104 A.D.3d 37, 48 (2d Dep't 2012)
(“Based on the express preemption provision set forth in 42 USC § 1395w-26(b)(3), as well as
the regulations set forth in 42 CFR 422.108(f), we hold that General Obligations Law § 5-335,
insofar as applied to Medicare Advantage organizations under Part C, is preempted by federal law
since it would impermissibly constrain contractual reimbursement rights authorized under the
"Organization as secondary payer" provisions of the Medicare Act.”). Moreover, several federal
courts have ruled that a MAP provider can also bring a federal action to collect on its liens under
42 U.S.C. § 1395y(b)(3)(A) - and can seek double damages thereunder. See In re Avandia Mktg.,
685 F.3d 353, 360 (3d Cir. Pa. 2012); Collins v. Wellcare Healthcare Plans, Inc., 2014 U.S. Dist.
LEXIS 174420 (E.D. La. Dec. 16, 2014). The City, therefore, will require resolution of any
Medicare-related claims as a condition to any settlement in this matter, regardless whether the
claims are asserted by the government under a traditional Medicare plan or by a MAP under a
Medicare Part C.
Thank you for your attention to the foregoing. Should you have any questions, feel free to
contact the City’s Medicare Compliance Unit at medicare@law.nyc.gov.
PLEASE BE ADVISED THAT WE CANNOT FINALIZE ANY SETTLEMENT
WITH A CURRENT MEDICARE RECIPIENT WITHOUT FIRST RESOLVING
MEDICARE’S CLAIM.
Very truly yours,
Medicare Compliance Officer
Encl.
3 You should be aware that if CMS determines that Medicare's future interests were not adequately protected, CMS
may require that plaintiff expend up to the entire amount of the settlement on Medicare-covered expenses related to
the injury claimed in this lawsuit before Medicare will provide coverage for the further treatment of such injury. See
Cribb v. Sulzer Metco (US) Inc., 2012 U.S. Dist. LEXIS 134900 (E.D.N.C. Sept. 5, 2012); Sipler v. Trans Am
Trucking, Inc., 881 F. Supp. 2d 635, 638 (D.N.J. 2012). Accordingly, we suggest that plaintiff evaluate her future
medical needs with her physicians and consider creating a Medicare set-aside instrument at the appropriate time.
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The City of New York
MURIEL GOODE-TRUFANT LAW DEPARTMENT
Acting Corporation Counsel 100 CHURCH STREET
NEW YORK, NEW YORK 10007
June 20, 2024
THE LAW OFFICE OF KATHERINE E. SMITH
233 Broadway, Suite 900
New York, NY 10279
Re: TYMERE JOHNSON v. CITY OF NEW YORK, et al.
County: Kings Ct. Index No.: 514224/2024
Our File No.: 2024-047735
Dear Counselors:
This office is unable to evaluate and review your client’s claims against THE CITY OF NEW
YORK, ("CITY") without duly executed authorizations permitting the CITY to review records pertaining
to your client’s arrest, incarceration, and or criminal proceedings. A review of the file in the above named
action reveals that you have yet to provide said authorizations. In order to facilitate the discovery process,
please provide this office with the following:
• Duly executed authorization permitting the Office of the Acting Corporation Counsel of
the City of New York to examine and copy the records, transcripts and certificates of
disposition of any criminal proceedings concerning the claims alleged in the complaint;
• Duly executed authorization permitting the Office of the Acting Corporation Counsel of
the City of New York to examine and copy all records, created by, or in the possession of,
the New York City Police Department, relating to the claims alleged in the complaint; and
• Duly executed authorization permitting the Office of the Acting Corporation Counsel of
the City of New York to examine and copy all records, created by, or in the possession of,
the District Attorney’s Office, relating to the claims alleged in the complaint.
Enclosed is a blank authorization for your convenience. Please copy and have your client complete
a separate original authorization for the New York City Police Department, District Attorney’s Office, and
the unsealing of related criminal court records and return them to the New York City Law Department, 100
Church Street, New York, NY 10007 at your earliest convenience. NOTE: - For cases with more than one
plaintiff please copy the blank authorization supplied herewith and return a separate set of completed
authorizations for each plaintiff alleging other than only loss of consortium claims. Thank you for your
anticipated cooperation.
Very truly yours,
MURIEL GOODE-TRUFANT
Acting Corporation Counsel
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CONSENT AND AUTHORIZATION FOR RELEASE OF RECORDS SEALED BY
LAW, INCLUDING RECORDS SEALED PURSUANT TO CRIMINAL PROCEDURE
LAW § 160.50
Whereas, I, _____________________________________, residing at
________________________________________________, date of birth: ________________, and
Social Security # _______________, NYSID # _______________, having caused a notice of claim to be
filed or commencing an action/lawsuit against THE CITY OF NEW YORK,, demanding money damages
for false arrest, false imprisonment, malicious prosecution, assault and battery, and/or other allegations, I
hereby waive my statutory rights, for purposes of this claim/action/lawsuit, to keep sealed the records of
my arrest on or about February 3, 2023 and prosecution, including all records maintained by law
enforcement agencies, criminal courts, and/or district attorney’s office. If my case proceeded in the
criminal courts, the docket # was _______________.
Whereas, it is necessary for the above named defendant(s) to have access to the aforementioned records
of my arrest and any related criminal proceedings and incarceration in order to evaluate and review my
claims, and prepare its defense thereto, I hereby authorize any and all governmental agencies, bodies and
employees having custody of such records to release such records to the Office of the Comptroller or the
Office of the Acting Corporation Counsel, or its authorized agent or employee. I specifically authorize
the New York City Police Department; Kings County District Attorney’s Office; New York State
Supreme Court, Kings County, Criminal Term; and New York City Criminal Court to disclose any and all
records in their possession relating to the aforementioned arrest/prosecution and docket number to the
Office of the Acting Corporation Counsel, or its authorized agent or employee.
____________________________________
Plaintiff/Claimant
Sworn to before me this ______ day of ____________, 20___
______________________________
NOTARY PUBLIC
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SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
----------------------------------------------------------------- x
TYMERE JOHNSON,
ANSWER
Plaintiff(s),
-against- Index #: 514224/2024
CITY OF NEW YORK; POLICE OFFICER DENNIS M. Law Dept. #: 2024-047735
DIAZ (SHIELD NO. 1270); NYPD OFFICERS JOHN
AND JANE DOE 1 THROUGH 10, (THE NAMES JOHN
AND JANE DOE BEING FICTITIOUS, AS THE TRUE
NAMES ARE PRESENTLY UNKNOWN),
Defendant(s).
----------------------------------------------------------------- x
Defendant CITY OF NEW YORK, by MURIEL GOODE-TRUFANT, Acting
Corporation Counsel, answering the complaint, allege upon information and belief:
1. Deny each allegation set forth in paragraph(s) 8-10, 12-15, 19, 21-22, 27-
28, 30-33, 35, 39-40, 42-44, 46, 48-51, 53-55, 59, 62, 65-66, 68-75, 77, 79-81, 83, 85-86, 89-91,
93-96, 98-99, 101-105, inclusive.
2. Deny knowledge or information sufficient to form a belief with respect to
the truth of the allegations set forth in paragraph(s) 1, 4-7, 16-18, 24, 36-37, 58, 60-61, 64, 88, 97,
inclusive.
3. Deny each allegation set forth in paragraph(s) 2-3, inclusive, except that
City of New York is a municipal corporation which maintains a Police Department pursuant to
law.
4. Deny each allegation set forth in paragraph(s) 20, 23, 29, 34, 41, 47, 52, 56,
57, 63, 67, 76, 82, 84, 87, 92, 100, inclusive, except as otherwise pleaded herein.
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5. Deny each allegation set forth in paragraph(s) designated 11, 25-26, 38, 45,
78, inclusive, as the same are conclusory and evidentiary and present questions of law and fact
which should be reserved for decision at the time of trial.
AFFIRMATIVE DEFENSE(S)
6. Plaintiff(s)’ culpable conduct caused or contributed, in whole or in part, to
his/her/their injuries and or damages.
7. At all times mentioned in the complaint, plaintiff(s) knew or should have
known in the exercise of due/reasonable care of the risks and dangers incident to engaging in the
activity alleged. Plaintiff(s) voluntarily performed and engaged in the alleged activity and
assumed the risk of the injuries and/or damages claimed. Plaintiff(s) failed to use all required,
proper, appropriate and reasonable safety devices and/or equipment and failed to take all proper,
appropriate and reasonable steps to assure his/her/their safety. Plaintiff(s)’ primary assumption of
risk solely caused his/her/their injuries and/or damage and defendant(s) owed no duty to the
plaintiff(s) with respect to the risk assumed. Plaintiff(s)’ express assumption of risk solely caused
his/her/their injuries and/or damage and defendant(s) owed no duty to the plaintiff(s) with respect
to the risk assumed. Plaintiff(s)’ implied assumption of risk caused or contributed, in whole or in
part to his/her/their injuries. In any action for injuries arising from the use of a vehicle in, or upon
which plaintiff(s) were riding; it will be claimed that the injuries and/or damages sustained were
caused by the failure of the plaintiff(s) to use available seat-belts and/or other safety devices.
8. Defendants are immune from suit for their exercise of discretion in the
performance of a governmental function and/or their exercise of professional judgment.
9. The amounts recoverable by plaintiff(s) are subject to limitation pursuant to
Section 1601 of the Civil Practice Law and Rules, by reason of the culpable conduct of other
person(s) who are, or with reasonable diligence could have been made party defendant(s) to this
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action, or pursuant to Section 15-108 of the General Obligations Law, by reason of a prior
settlement between plaintiff(s) and said person(s), or pursuant to Section 4545 of the Civil Practice
Law and Rules are subject to reduction by collateral sources received by plaintiff(s), or by reason
of the fact that punitive damages are not recoverable against municipal defendant(s).
10. If plaintiff demonstrates that the acts complained of were undertaken in the
scope of the actor(s) employment, then such acts as may have been committed by law enforcement
officers in the employ of the City of New York were justified as being reasonably necessary, and
were committed in good faith without malice and with probable cause, and in the exercise of
professional judgment or the performance of discretionary functions for which defendant(s) are
qualifiedly privileged under the laws of this State and of the United States. Individual defendant(s)
represented by the Office of the Acting Corporation Counsel of the City of New York(if any) did
not violate any clearly established constitutional or statutory right of which a reasonable person
would have known and therefore are/is protected by qualified immunity.
11. Such statements as were made concerning the plaintiff(s) were privileged
as being true, or fair comment upon matters of opinion, and were made in the good faith belief in
their truth without malice to person(s) having a like duty or interest therein.
12. The action on behalf of the plaintiff(s) is barred by reason of the fact that it
was not commenced within the time provided by the Statute of Limitations.
13. Plaintiff(s)’ complaint fails to state a cause of action upon which relief can
be granted.
14. Plaintiff(s)’ complaint fails to allege a prima facie case against the
defendant answering hereby.
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WHEREFORE, defendant(s) demand judgment dismissing the complaint and all
cross-claims against them, or, in the event that they are adjudged liable, granting judgment over,
or apportioning such liability in accordance with their equitable shares of responsibility, and
awarding the costs of this action, together with such other and further relief as to the court may
seem just.
MURIEL GOODE-TRUFANT
Acting Corporation Counsel
100 Church Street
New York, New York 10007
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Index #: 514224/2024
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
TYMERE JOHNSON,
Plaintiff(s),
- against -
CITY OF NEW YORK; POLICE OFFICER DENNIS M. DIAZ (SHIELD NO.
1270); NYPD OFFICERS JOHN AND JANE DOE 1 THROUGH 10, (THE
NAMES JOHN AND JANE DOE BEING FICTITIOUS, AS THE TRUE
NAMES ARE PRESENTLY UNKNOWN),
Defendant(s).
COMBINED DEMAND FOR
BILL OF PARTICULARS & DISCOVERY
MURIEL GOODE-TRUFANT
Acting Corporation Counsel
Attorney for Defendant THE CITY OF NEW YORK,100 Church Street
New York, New York 10007
Telephone Numbers:
Early Intervention Unit (settlements – all Boroughs)
(212) 356-1665
Pleadings Unit (212) 356-3235 (pleadings matters only)
All Other Matters (Inquire by county of venue)
Bronx Office: (718) 503-5030 (EBT’s - 5045)
Brooklyn Office: (718) 834-4600 (EBT’s - 4475)
Manhattan Office: (212) 356-2725 (EBT's-2791)
Queens Office: (718) 558-2100 (EBT's - 2105)
Staten Island Office: (718) 876-3600 (EBT's-3603)
Please refer to the following Law Dept. #: 2024-047735
and indicate the County in which the action is pending in all papers,
correspondence and other communications with respect thereto.
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SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
------------------------------------------------------------------------ x
TYMERE JOHNSON,
COMBINED DEMAND FOR
Plaintiff(s), VERIFIED BILL OF
PARTICULARS & DISCOVERY
-against-
CITY OF NEW YORK; POLICE OFFICER DENNIS M. DIAZ
(SHIELD NO. 1270); NYPD OFFICERS JOHN AND JANE
DOE 1 THROUGH 10, (THE NAMES JOHN AND JANE DOE
BEING FICTITIOUS, AS THE TRUE NAMES ARE
PRESENTLY UNKNOWN),
Defendant(s).
------------------------------------------------------------------------ x
DEMAND FOR VERIFIED BILL OF PARTICULARS
PLEASE TAKE NOTICE that pursuant to CPLR 3041, plaintiff(s) is required within 30
days following service of this demand to serve upon MURIEL GOODE-TRUFANT, Acting Corporation
Counsel, a verified bill of particulars setting forth in reasonable detail a statement of the following:
1. The exact date and time of the act or occurrence.
2. The specific location of the act or occurrence with reference to addresses, landmarks, or
other identifying points of reference, including the direction and distance therefrom. If the occurrence took
place inside a premise, state specifically the location within the premise and also include the block and lot of
the premises.
3. State the injuries claimed, if any.
4. State those injuries claimed to be permanent.
5. If applicable, set forth the length of time it is alleged the plaintiff(s) was confined to:
(a) Hospital(s);
(b) Bed;
(c) House.
6. If applicable, set forth the amount claimed as special damages for:
(a) Physician(s) services;
(b) Nurses services;
(c) Hospital expenses;
(d) Drugs and medical supplies;
(e) X-rays and diagnostic tests.
For each of the foregoing elements of damages please state the name and address(es) of the
provider(s) and the dates of treatment. If any of the foregoing elements of damages have been repaid to the
plaintiff(s) or otherwise paid for by other sources, identify each type of service recompensed, the source or
sources of such recompense, the amount so paid and the net amount of out of pocket expenses sustained by the
plaintiff(s).
7. If applicable, state the total amount of all other special damages not specified in items
above; and please state the
(a) name and address of each service provider;
(b) each date of the service;
(c) amount of the expense for each provider;
(d) amount of any expense paid by a third-party (including any payment made to
reimburse plaintiff);
(e) name and address of the third-party paying any expense; and
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(f) amount of any unreimbursed expense paid by plaintiff(s) personally to each
provider.
8. State the occupation of plaintiff(s) at the time of the incident; and please state the:
(a) name and address of any employer for 5 years prior to alleged incident and up to
the time of trial;
(b) length of time totally disabled from work;
(c) length of time partially disabled from work;
(d) amount claimed for lost earnings, if any;
i. if a loss of earnings claim is alleged, please state the yearly gross earnings for
each year during 5 years prior to alleged incident and up to the time of trial;
and
(e) number of days absent from work as a result of injuries sustained from the
incident.
9. State the (a) name and address of any school attended by plaintiff(s) for 5 years prior to
alleged incident and up to the time of trial; and (b) the number of days lost from school as a result of injuries
sustained from incident.
10. State the home address of plaintiff(s) for a period of 5 years prior to the alleged incident
to the present.
11. State any other name used by plaintiff(s) and the time period when the name was used.
12. State the date of birth and social security number of plaintiff(s) (this request is made
pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007, 42 U.S.C. §1395
(B)(8)).
13. State whether plaintiff(s) is (are) or ever was (were) a Medicare recipient(s). If plaintiff
is (are) or ever was (were) a Medicare recipient, provide their Medicare Beneficiary Identifier (MBI)
number and respond to the following:.
a. State whether plaintiff(s) is (are) or ever was (were) enrolled in any Medicare
Advantage Plan (MAP) also known as Medicare Part C. If Plaintiff is or was
enrolled in a MAP, please provide the policy/plan number and effective date(s)
of coverage along with copies of any insurance cards since the date of
accident/incident and all Explanation of Benefits (EOB) statements related to the
subject accident/incident;
b. State whether plaintiff (s) is (are) or was (were) enrolled in a Prescription Drug
Plan (PDP) also known as Medicare Part D. If Plaintiff is or was enrolled in a
PDP, please provide the policy/plan number and effective date(s) of coverage
along with copies of any insurance cards since the date of accident/incident and
all Explanation of Benefits (EOB) statements related to the subject
accident/incident;
14. State whether plaintiff(s) is (are) or ever was (were) a Medicaid recipient(s). If plaintiff
is or was a Medicaid recipient please provide the following:.
a. Plaintiff’s Client Identification Number (CIN);
b. A copy of any and all Medicaid Identification cards;
c. A copy of the Notice that was provided to HRA pursuant to CPLR§306-c and
filed with the Court.
15. Please state whether plaintiff(s) is (are) or ever was (were) receiving Social Disability
Income (SSDI) and to/from dates that benefits were received and amount of said benefits.
16. If plaintiff(s) has (have) ever been convicted of a crime (including any guilty plea),
please state (a) the NYSID number of plaintiff; (b) the dates of every conviction; (c) whether the conviction
was state or federal; and (d) the county where each conviction occurred.
17. If the complaint alleges loss of services, set forth the pecuniary loss, if any, alleged in the
complaint. Enumerate the damages for:
(a) Loss of services;
(b) Consortium;
(c) Other expenses.
18. State those injuries arising from the use or operation of a motor vehicle which are
claimed to be serious, as defined in Insurance Law § 5102 (d), if any.
19. If property damage is claimed, please state (a) all property damaged; (b) the fair market
value of each item at the time it was damaged; (c) the cost of repairing each item; (d) the cost of replacing
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each item; (e) the date each item was acquired; (f) the purchase cost of each item; (g) the amount(s) provided
by a third-party to reimburse damage; (h) the name and address of any third-party which reimbursed damage;
and (i) amount of any unreimbursed payment made by plaintiff(s) to replace or repair a damaged item.
20. State the manner in which it is claimed the accident occurred.
21. State separately the acts or omissions constituting the alleged negligence of each of the
answering defendant(s), if any.
22. State separately the acts of each of the answering defendant(s) constituting the
intentional wrongs claimed, if any.
23. State the names of the employee(s) or agents of the answering defendant(s) who are
alleged to have committed the acts set forth in the items above.
24. Describe any alleged dangerous and defective condition and or the object or
instrumentality complained of, as well as the nature of the condition alleged.
25. State whether any repairs were made prior to the happening of the alleged accident.
26. If it is alleged that repairs were made prior to the happening of the accident, state when,
where, and by whom, the repairs were made.
27. State whether actual or constructive notice is claimed or whether it is alleged that
defendant created the condition complained of.
28. If actual notice is claimed, then set forth the following:
(a) The names of the employees, agents and/or servants of the defendant(s) to
whom it will be alleged said actual notice was given;
(b) By whom will it be claimed that said actual notice was given on each occasion
aforesaid;
(c) The date or dates of each said notice;
(d) The place said actual notice was given.
29. If constructive notice is claimed, state the length of time said condition is alleged to have
existed prior to the happening of the alleged occurrence.
30. If prior written notice is claimed, specify the nature of such notice.
31. If prior written notice is claimed, then set forth the following:
(a) The name(s) of the entity, agency, employees, agents and/or servants of the
defendant(s) to whom it will be alleged said prior written notice was given;
(b) By whom will it be claimed that said prior written notice was given on each
occasion aforesaid;
(c) The date or dates of each said notice;
(d) The place said notice was given.
32. In any action where plaintiff(s) claim the violation of any statute, ordinance, rule, order,
requirement or regulation, state separately and specifically all such statutes, ordinances, rules or regulations
alleged to have been violated by the answering defendant(s).
33. If applicable, describe in what respects defendant(s) failed to provide plaintiff(s) with a
safe place to work.
34. If applicable, state whether plaintiff(s) will allege that this defendant(s) was a party to a
contract. If yes;
(a) State the parties to the contract;
(b) State the contract number.
35. If applicable, set forth each and every item of construction, excavation or demolition work
which the plaintiff(s) will allege was not so constructed, shored, equipped, guarded, arranged, operated and
conducted as to provide reasonable and adequate safety; setting forth the manner in which the construction,
shoring, equipping, guarding, arranging, operating and/or conducting of the construction, excavating, or
demolition work is alleged to have caused the plaintiff(s) alleged injury.
36. If applicable, state whether the plaintiff(s) will allege that this defendant(s) exercised
control over the work being performed at the job site. If yes, state the nature and extent of the control allegedly
exercised and the exact manner in which said control was exercised.
37. If applicable, state those injuries claimed to be “grave”, as defined in the Workers’
Compensation Law § 11.
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