Preview
INDEX NO. 157967/2015
Dy FRECUEST BE Cede TSK EFor 7
NYSCEF FOR JUDICIAL INTERVENTION Lire
Ucs-840 (7/2012) 1% S ony Dae
Supreme COURT, COUNTY OF. New York
Judge Assigned
Index No: Date Index Issued:
Enter the complete case caption. Do not use et al or et ano. If more space is required, RIT Date
CAPTION: attach a caption rider sheet.
ICOUNTRY-WIDE INSURANCE COMPANY,
Plaintiff(s)/Petitioner(s)
-against-
|'C ACUPUNCTURE, P.C. a/a/o COREY CRICHLOW,
Respondent(s),
Defendant(s)/Respondent(s)
NATURE OF ACTION OR PROCEEDING: Check ONE box only and specify where indicated.
MATRIMONIAL COMMERCIAL
© Contested © Business Entity (including corporations, partnerships, LLCs, etc.)
NOTE: For all Matrimonial actions where the parties have children under O Contract
the age of 18, complete and attach the MATRIMONIAL RJI Addendum. O insurance (where insurer is a party, except arbitration)
For Uncontested Matrimonial actions, use RJI form UD-13. © UCC (including sales, negotiable instruments)
TORTS © Other Commercial:
© Asbestos (cpeaty)
© Breast Implant NOTE: For Commercial Division assignment requests [22 NYCRR §
© Environmental: 202.70(d)], complete and attach the COMMERCIAL DIV RJI Addendum
(speaiiy) REAL PROPERTY: How many properties does the application include?
© Medical, Dental, or Podiatric Malpractice © Condemnation
© Motor Vehicle © Mortgage Foreclosure (speciy): O Residentiat O commercial
© Products Liability: Property Address:
(specify) Street Address, city stale Zip
© other Negligence: NOTE: For Mortgage Foreclosure actions involving a one- to four-family,
(specify) owner-occupied, residential property, or an owner-occupied
© Other Professional Malpractice: condominium, complete and attach the FORECLOSURE RJI Addendum.
(speciy) © Tax Certiorari - Section: Block: Lot: =
O other Tort: © Tax Foreclosure
(specify) © other Real Property:__
(specily)
OTHER MATTERS
© Certificate of Incorporation/Dissolution (see NOTE under Commercial] SPECIAL PROCEEDINGS
© Emergency Medical Treatment © CPLR Article 75 (Arbitration) [see NOTE under Commercial]
O Habeas Corpus © CPLR Article 78 (Body or Officer)
© Local Court Appeal © Election Law
© Mechanic's Lien © MHL Article 9.60 (Kendra’s Law)
O Name Change © MHL Article 10 (Sex Offender Confinement-tnitial)
© Pistol Permit Revocation Hearing © MHL Article 10 (Sex Offender Continement-Review)
© Sale or Finance of Religious/Not-for-Profit Property © MHL Article 81 (Guardianship)
O Other: O Other Mental Hygiene:__ =
(specily) (specify)
© Other Special Proceeding:
(speciy)
STATUS OF ACTION OR PROCEEDING: Answer YES or NO for EVERY question AND enter additional information where indicated.
YES | NO
Has a summons and complaint or summons winotice been filed? Oo © Ifyes, date filed: as
Has a summons and complaint or summons winotice been served? Oo © Ifyes, date served
Is this action/proceeding being filed post-judgment? Oo © Ifyes, judgment date:
[NATURE OF JUDICIAL INTERVENTION: Check ONE box only AND enter additional information where indicated.
© infant's Compromise
© Note of Issue and/or Certificate of Readiness
© Notice of Medical, Dental, or Podiatric Malpractice Date Issue Joined:
O Notice of Motion Relief Sought: Return Date:
© Notice of Petition Relief Sought: V2" jon/Order/Judgment/Award Return Date: 08/26/2015
© Order to Show Cause Relief Sought: Retum Date:
© Other Ex Parte Application Relief Sough
© Poor Person Application
© Request for Preliminary Conference
© Residential Mortgage Foreclosure Settlement Conference
© writ of Habeas Corpus
© Other (specify):
Uist any related actions. For Matrimonial actions, include any related criminal and/or Family Court cases.
RELATED CASES: If additional space is required, complete and attach the RJl Addendum. If none, leave blank.
Case Title Index/Case No. Court Judge (if assigned) Relationship to Instant Case
PARTIES:
For parties without an allomey, chack "Un-Rep" box AND enter parly address, phone number and e-mail address in space provided
If additional space is required, complete and attach the RJI Addendum.
Parties: Attorneys and/or Unrepresented igants: sue
Un- List parties in caption order and Provide atlorney name, firm name, business address, phone number and e-mail Joined Insurance
Carrier(s):
Rep indicate party role(s) (e.g. defendant; address of all attorneys that have appeared in the case. For unrepresented (YIN):
3rd-party plaintiff) litigants, provide address, phone number and e-mail address.
[Country-Wide Insurance Company Last Name First Name K®)ves
Jaffe & Koumourdas, LLP lcountry-Wide
First Name Firm Name
O Primary Role: (0 Wall Street, 12th Floor New York New York. 10005 insurance Company
Petitioner Street Address. city State zip {No
Secondary Role (if any): +1 (212) 209.7800
Fax e-mail
IT.c. Acupuncture, P.C. Last Name First Name
Last Name Ke)YEs
ITC Acupuncture, P.C.
First Name Firm Name
Primary Role: 755 Ocean Parkway, Suite 18 Brooklyn New York. 11223
Respondent Street Address, city State Zip No
‘Secondary Role (if any)
Phone Fax e-mail
Last Name Last Name First Name (ves
First Name Firm Name
Primary Role:
Street Address. city State Zip Kno
Secondary Role (if any):
Phone Fax esnail
Last Name Last Name First Name (ves
First Name Firm Name
0 Primary Role:
“1 Zip
Street Address city (Dno
Secondary Role (if any):
Phone Fax
| AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS|NOTED ABOVE, THERE ARE AND HAVE
BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVE! JON PREVIOUSLY BEEN FILED IN
THIS ACTION OR PROCEEDING. |
Dated: 07/30/2015
| J
v “SIGNATURE
RICHARD SADOWSKI
ATTORNEY REGISTRATION NUMBER PRINT OR TYPE NAME
Preview
INDEX NO. 157967/2015 Dy FRECUEST BE Cede TSK EFor 7 NYSCEF FOR JUDICIAL INTERVENTION Lire Ucs-840 (7/2012) 1% S ony Dae Supreme COURT, COUNTY OF. New York Judge Assigned Index No: Date Index Issued: Enter the complete case caption. Do not use et al or et ano. If more space is required, RIT Date CAPTION: attach a caption rider sheet. ICOUNTRY-WIDE INSURANCE COMPANY, Plaintiff(s)/Petitioner(s) -against- |'C ACUPUNCTURE, P.C. a/a/o COREY CRICHLOW, Respondent(s), Defendant(s)/Respondent(s) NATURE OF ACTION OR PROCEEDING: Check ONE box only and specify where indicated. MATRIMONIAL COMMERCIAL © Contested © Business Entity (including corporations, partnerships, LLCs, etc.) NOTE: For all Matrimonial actions where the parties have children under O Contract the age of 18, complete and attach the MATRIMONIAL RJI Addendum. O insurance (where insurer is a party, except arbitration) For Uncontested Matrimonial actions, use RJI form UD-13. © UCC (including sales, negotiable instruments) TORTS © Other Commercial: © Asbestos (cpeaty) © Breast Implant NOTE: For Commercial Division assignment requests [22 NYCRR § © Environmental: 202.70(d)], complete and attach the COMMERCIAL DIV RJI Addendum (speaiiy) REAL PROPERTY: How many properties does the application include? © Medical, Dental, or Podiatric Malpractice © Condemnation © Motor Vehicle © Mortgage Foreclosure (speciy): O Residentiat O commercial © Products Liability: Property Address: (specify) Street Address, city stale Zip © other Negligence: NOTE: For Mortgage Foreclosure actions involving a one- to four-family, (specify) owner-occupied, residential property, or an owner-occupied © Other Professional Malpractice: condominium, complete and attach the FORECLOSURE RJI Addendum. (speciy) © Tax Certiorari - Section: Block: Lot: = O other Tort: © Tax Foreclosure (specify) © other Real Property:__ (specily) OTHER MATTERS © Certificate of Incorporation/Dissolution (see NOTE under Commercial] SPECIAL PROCEEDINGS © Emergency Medical Treatment © CPLR Article 75 (Arbitration) [see NOTE under Commercial] O Habeas Corpus © CPLR Article 78 (Body or Officer) © Local Court Appeal © Election Law © Mechanic's Lien © MHL Article 9.60 (Kendra’s Law) O Name Change © MHL Article 10 (Sex Offender Confinement-tnitial) © Pistol Permit Revocation Hearing © MHL Article 10 (Sex Offender Continement-Review) © Sale or Finance of Religious/Not-for-Profit Property © MHL Article 81 (Guardianship) O Other: O Other Mental Hygiene:__ = (specily) (specify) © Other Special Proceeding: (speciy) STATUS OF ACTION OR PROCEEDING: Answer YES or NO for EVERY question AND enter additional information where indicated. YES | NO Has a summons and complaint or summons winotice been filed? Oo © Ifyes, date filed: as Has a summons and complaint or summons winotice been served? Oo © Ifyes, date served Is this action/proceeding being filed post-judgment? Oo © Ifyes, judgment date: [NATURE OF JUDICIAL INTERVENTION: Check ONE box only AND enter additional information where indicated. © infant's Compromise © Note of Issue and/or Certificate of Readiness © Notice of Medical, Dental, or Podiatric Malpractice Date Issue Joined: O Notice of Motion Relief Sought: Return Date: © Notice of Petition Relief Sought: V2" jon/Order/Judgment/Award Return Date: 08/26/2015 © Order to Show Cause Relief Sought: Retum Date: © Other Ex Parte Application Relief Sough © Poor Person Application © Request for Preliminary Conference © Residential Mortgage Foreclosure Settlement Conference © writ of Habeas Corpus © Other (specify): Uist any related actions. For Matrimonial actions, include any related criminal and/or Family Court cases. RELATED CASES: If additional space is required, complete and attach the RJl Addendum. If none, leave blank. Case Title Index/Case No. Court Judge (if assigned) Relationship to Instant Case PARTIES: For parties without an allomey, chack "Un-Rep" box AND enter parly address, phone number and e-mail address in space provided If additional space is required, complete and attach the RJI Addendum. Parties: Attorneys and/or Unrepresented igants: sue Un- List parties in caption order and Provide atlorney name, firm name, business address, phone number and e-mail Joined Insurance Carrier(s): Rep indicate party role(s) (e.g. defendant; address of all attorneys that have appeared in the case. For unrepresented (YIN): 3rd-party plaintiff) litigants, provide address, phone number and e-mail address. [Country-Wide Insurance Company Last Name First Name K®)ves Jaffe & Koumourdas, LLP lcountry-Wide First Name Firm Name O Primary Role: (0 Wall Street, 12th Floor New York New York. 10005 insurance Company Petitioner Street Address. city State zip {No Secondary Role (if any): +1 (212) 209.7800 Fax e-mail IT.c. Acupuncture, P.C. Last Name First Name Last Name Ke)YEs ITC Acupuncture, P.C. First Name Firm Name Primary Role: 755 Ocean Parkway, Suite 18 Brooklyn New York. 11223 Respondent Street Address, city State Zip No ‘Secondary Role (if any) Phone Fax e-mail Last Name Last Name First Name (ves First Name Firm Name Primary Role: Street Address. city State Zip Kno Secondary Role (if any): Phone Fax esnail Last Name Last Name First Name (ves First Name Firm Name 0 Primary Role: “1 Zip Street Address city (Dno Secondary Role (if any): Phone Fax | AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS|NOTED ABOVE, THERE ARE AND HAVE BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVE! JON PREVIOUSLY BEEN FILED IN THIS ACTION OR PROCEEDING. | Dated: 07/30/2015 | J v “SIGNATURE RICHARD SADOWSKI ATTORNEY REGISTRATION NUMBER PRINT OR TYPE NAME