Preview
FILED: NEW YORK COUNTY CLERK 07/14/2020 02:15 PM INDEX NO. 654092/2019
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 07/14/2020
REQUEST FOR JUDICIAL INTERVENTION 58,4g°g1,)
New York Supi-ême COURT, COUNTY OF New York
Index No: 654092/2019 Date Index Issued: 07/18/2019 For Court Use Only:
IAS EntryDate
LIBERTY MUTUAL INSURANCE COMPANY, LM GENERAL INSURANCE COMPANY
Judge Assigned
-against- Plaintiff(s)/Petitioner(s)
KENDON THOMAS, AMRO CARE PT, P.C.,LAWRENCE CHIROPRACTIC DIAGNOSTIC SERVICES, NORTH SHORE HOME
CARE SERVICES, INC.,AVA CUSTOM SUPPLY INC.,OPUS PSYCHOLOGICAL SERVICES P.C.,SI ACUPUNCTURE, PC, RJIFiled Date
METRO PAIN SPECIALISTS PROFESSIONAL CORPORATION, PROSPECT CHIROPRACTIC PLLC, CITIMEDICAL I, PLLC,
MAUR...
Defendant(s)/Respondent's)
COMMERCIAL MATRIMONIAL
O Contested
O BusinessEntity (includes corporations, rmstrarchips, LLCs,LLPs,etc.)
NOTE: If there are children under the age of 18, complete and attach the
Contract MATRIMONIAL RJIAddendum (UCS-84OM).
Insurance(where insurance company is a party, except arbitration) . .
For UncontestedMatnmonial actions, use the UncontestedDivorce RJi(UD-13).
O UCC(includes sales and negotiable instruments)
Other Commercial(specify):
TORTS
NOTE: For CommercialDivision assignment requests pursuant to 22 NYCRR202.70(d),
complete and attach the COMMERCIALDIVISION RJIADDENDUM (UCS-840C). Asbestos
O Child Victims Act
REAL PROPERTY: Specify how many properties the application includes: Fr±enm±M (specify):
O
O Condemnation Medical,Dental, or Podiatric Malpractice
O O Residential
Mortgage Foreclosure(specify): O Commercial O Motor Vehicle
Property Address: O Products Liability (specify):
Other Negligence(specify):
NOTE: For Mortgage Foreclosureactions involving a one to four-family, owner-
occupied residential property or owner-occupiedcondominium, complete and
O Other ProfessionalMalpractice (specify):
attach the FORECLOSURERJIADDENDUM (UCS-840F). Other Tort (specify):
Tax Certiorari - Section: Block: Lot:
Tax Foreclosure SPECIAL PROCEEDINGS
Other Real Property (specify): O CPLRArticle 75 (Arbitration)
[see NOTE in COMMERCIALsection]
O
O CPLRArticle 78 (Body or Officer)
OTHER MATTERS
O Election Law
O Certificate of incorporatiort/Disc:ut|ca
[see NOTE in COMMERCIALsection] Extreme Risk ProtectionOrder
O Emergency MedicalTreatment MHLArticle 9.60 (Kendra's Law)
O HabeasCorpus O MHLArticle 10 (Sex Offender Confinement-Initial)
O LocalCourt Appeal MHLArticle 10 (Sex Offender Confinement-Review)
O Mechanic'sLien MHLArticle 81 (Guardianship)
O NameChange O Other Mental Hygiene (specify):
Pistol Permit Revocation Hearing O Other Special Proceeding(specify):
O Saleor Financeof Religious/Not-for-ProfitProperty
O Other (specify):
STATUS OF ACTION OR PROCEEDING: AnswerYESor NOfor every question and enter additional information where indicated.
YES NO
Hasa summons and complaint or summonswith notice been filed? O 07/17R020
If yes, date filed:
Hasa summons and complaint or summonswith notice been served? O GB164020
If yes, date served:
Is this action/proceeding being filed post-judgment? O If yes, judgment date:
NATURE OF JUDICIAL INTERVENTION: Checkone box only and enter additional info=2tion
where indicated.
O Infant's Compromise
O Extreme Risk ProtectionOrder Application
O Note of Issue/Certificateof Readiness
O Date Issuejoined:
Notice of Medical, Dental, or Podiatric Malpractice
|udgment - Default
Relief Requested: Return Date:08/17R020
Notice of Motion
Notice of Petition Relief Requested: Return Date:
O
Order to ShowCause Relief Requested: Return Date:
O
Other Ex ParteApplication Relief Requested:
O PoorPersonApplication
O Requestfor i¾e-liwi;nârfConference
O ResidentialMortgage ForeclosureSettlement Conference
O Writ of HabeasCorpus
O Other (specify):
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FILED: NEW YORK COUNTY CLERK 07/14/2020 02:15 PM INDEX NO. 654092/2019
NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 07/14/2020
RELATED CASES: List any related
actions.For Matrimonial
cases,list any
relatedcriminal
or FamilyCourtcases.If none,
leave blank.If additional
space
is required,
complete and attachthe RJI Addendum (UCS-840A).
Case Title Index/Case Number Court Judge (ifassigned) Relationship to instantcase
For parties
withoutan attorney,
check the"Un-Rep" box and enter
the party's phone number and emailin thespace
PARTIES: address,
provided.If additional
space is required,
completeand attachthe RJI Addendum (UCS-840A).
Un- Parties Attorneys and/or Unrepresented Litigants Issue Joined | Insurance
Rep List parties in same order as listed in the
For represented parties, provide attorney's name, firm name, address, phone
For each defendant,
For each defendant,
caption and indicate roles (e.g., plaintiff,
and email. For unrepresented parties, provide party's address, phone and
indicate if issue has
indicate insurance
defendant; 3rdparty plaintiff, etC.) email. beenjoined. carrier, if applicable.
Name: LIBERTY MUTUAL ASHER GROSSMAN, Law Offices ofBurke, &
Conway
INSURANCE COMPANY Stiefeld,10 Bank Street Suite1200, White Plains,NY E YES O NO
Role(s):Plaintiff/Petitioner 10601, 9149978100, wphicourtsefile@libertymutual.com
Name: LM GENERAL INSURANCE ASHER GROSSMAN, Law Offices ofBurke, &
Conway
COMPANY Stiefeld,10 Bank Street Suite1200, White Plains,NY E YES O NO
Role(s):Plaintiff/Petitioner 10601, 9149978100, wphicourtsefile@libertymutual.com
Name: THOMAS, KENDON 14521 Tuskegee Airman Way, Jamaica, NY 11435
O YES E NO
Role(s):Defendant/Respondent
Name: AMRO CARE PT, P.C· 2427 Coyle Street, Apt. 2,Brooklyln, NY 11235
O YES E NO
Role(s):Defendant/Respondent
Name: LAWRENCE CHIROPRACTIC 195-35 HollisAve., Basement, Hollis,NY 11423
DIAGNOSTIC SERVICES
O YES E NO
Role(s):Defendant/Respondent
Name: NORTH SHORE HOME CARE 46-28 243rd Street, Douglaston, NY 11362
SERVICES, INC.
O YES O NO
Role(s):Defendant/Respondent
Name: AVA CUSTOM SUPPLY INC· 3426 Guider Avenue, 1st Floor,Brooklyn, NY 11235
O YES E NO
Role(s):Defendant/Respondent
Name: OPUS PSYCHOLOGICAL 43-60 Douglaston, New York,NY 11363
SERVICES P.C.
O YES E NO
Role(s):Defendant/Respondent
Name: SI ACUPUNCTURE, PC 3 Dakota Drive, Suite300, Lake Success, NY 11042
O YES E NO
Role(s):Defendant/Respondent
Name: METRO PAIN SPECIALISTS OLEG RYBAK, THE RYBAK FIRM PLLC, 1810 VOORHIES
PROFESSIONAL CORPORATION AVENUE, SUITE 7 , Brooklyn,NY 11235, 718-975-2035, E YES O NO
Role(s):Defendant/Respondent orybak@rybakfirm.com
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR
PROCEEDINGS, EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION BEEN PREVIOUSLY FILED INTHIS
ACTION OR PROCEEDING.
Dated: 07/14/2020 ASHER G. GROSSMAN
Signature
5310982 ASHER G. GROSSMAN
Attorney Registration Number PrintName
This form was generated by NYSCEF
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FILED: NEW YORK COUNTY CLERK 07/14/2020 02:15 PM INDEX NO. 654092/2019
Caption
NYSCEF Rider
DOC. Sheet22
NO. RECEIVED NYSCEF: 07/14/2020
Plaintiff(s)/Petitioner(s)
VS.
KENDON THOMAS, AMRO CARE PT, P.C.,LAWRENCE CHIROPRACTIC DIAGNOSTIC SERVICES, NORTH SHORE HOME CARE
SERVICES, INC.,AVA CUSTOM SUPPLY INC.,OPUS PSYCHOLOGICAL SERVICES P.C., SIACUPUNCTURE, PC, METRO PAIN
SPECIALISTS PROFESSIONAL CORPORATION, PROSPECT CHIROPRACTIC PLLC, CITIMEDICAL I, PLLC, MAURO
CHIROPRACTIC P.C.,HARBOR MEDICAL GROUP PC, ACUTUS RX, LLC, AK GLOBAL SUPPLY CORP.
Defendant(s)/Respondent(s)
3 of 3
Preview
FILED: NEW YORK COUNTY CLERK 07/14/2020 02:15 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 07/14/2020 REQUEST FOR JUDICIAL INTERVENTION 58,4g°g1,) New York Supi-ême COURT, COUNTY OF New York Index No: 654092/2019 Date Index Issued: 07/18/2019 For Court Use Only: IAS EntryDate LIBERTY MUTUAL INSURANCE COMPANY, LM GENERAL INSURANCE COMPANY Judge Assigned -against- Plaintiff(s)/Petitioner(s) KENDON THOMAS, AMRO CARE PT, P.C.,LAWRENCE CHIROPRACTIC DIAGNOSTIC SERVICES, NORTH SHORE HOME CARE SERVICES, INC.,AVA CUSTOM SUPPLY INC.,OPUS PSYCHOLOGICAL SERVICES P.C.,SI ACUPUNCTURE, PC, RJIFiled Date METRO PAIN SPECIALISTS PROFESSIONAL CORPORATION, PROSPECT CHIROPRACTIC PLLC, CITIMEDICAL I, PLLC, MAUR... Defendant(s)/Respondent's) COMMERCIAL MATRIMONIAL O Contested O BusinessEntity (includes corporations, rmstrarchips, LLCs,LLPs,etc.) NOTE: If there are children under the age of 18, complete and attach the Contract MATRIMONIAL RJIAddendum (UCS-84OM). Insurance(where insurance company is a party, except arbitration) . . For UncontestedMatnmonial actions, use the UncontestedDivorce RJi(UD-13). O UCC(includes sales and negotiable instruments) Other Commercial(specify): TORTS NOTE: For CommercialDivision assignment requests pursuant to 22 NYCRR202.70(d), complete and attach the COMMERCIALDIVISION RJIADDENDUM (UCS-840C). Asbestos O Child Victims Act REAL PROPERTY: Specify how many properties the application includes: Fr±enm±M (specify): O O Condemnation Medical,Dental, or Podiatric Malpractice O O Residential Mortgage Foreclosure(specify): O Commercial O Motor Vehicle Property Address: O Products Liability (specify): Other Negligence(specify): NOTE: For Mortgage Foreclosureactions involving a one to four-family, owner- occupied residential property or owner-occupiedcondominium, complete and O Other ProfessionalMalpractice (specify): attach the FORECLOSURERJIADDENDUM (UCS-840F). Other Tort (specify): Tax Certiorari - Section: Block: Lot: Tax Foreclosure SPECIAL PROCEEDINGS Other Real Property (specify): O CPLRArticle 75 (Arbitration) [see NOTE in COMMERCIALsection] O O CPLRArticle 78 (Body or Officer) OTHER MATTERS O Election Law O Certificate of incorporatiort/Disc:ut|ca [see NOTE in COMMERCIALsection] Extreme Risk ProtectionOrder O Emergency MedicalTreatment MHLArticle 9.60 (Kendra's Law) O HabeasCorpus O MHLArticle 10 (Sex Offender Confinement-Initial) O LocalCourt Appeal MHLArticle 10 (Sex Offender Confinement-Review) O Mechanic'sLien MHLArticle 81 (Guardianship) O NameChange O Other Mental Hygiene (specify): Pistol Permit Revocation Hearing O Other Special Proceeding(specify): O Saleor Financeof Religious/Not-for-ProfitProperty O Other (specify): STATUS OF ACTION OR PROCEEDING: AnswerYESor NOfor every question and enter additional information where indicated. YES NO Hasa summons and complaint or summonswith notice been filed? O 07/17R020 If yes, date filed: Hasa summons and complaint or summonswith notice been served? O GB164020 If yes, date served: Is this action/proceeding being filed post-judgment? O If yes, judgment date: NATURE OF JUDICIAL INTERVENTION: Checkone box only and enter additional info=2tion where indicated. O Infant's Compromise O Extreme Risk ProtectionOrder Application O Note of Issue/Certificateof Readiness O Date Issuejoined: Notice of Medical, Dental, or Podiatric Malpractice |udgment - Default Relief Requested: Return Date:08/17R020 Notice of Motion Notice of Petition Relief Requested: Return Date: O Order to ShowCause Relief Requested: Return Date: O Other Ex ParteApplication Relief Requested: O PoorPersonApplication O Requestfor i¾e-liwi;nârfConference O ResidentialMortgage ForeclosureSettlement Conference O Writ of HabeasCorpus O Other (specify): 1 of 3 FILED: NEW YORK COUNTY CLERK 07/14/2020 02:15 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 07/14/2020 RELATED CASES: List any related actions.For Matrimonial cases,list any relatedcriminal or FamilyCourtcases.If none, leave blank.If additional space is required, complete and attachthe RJI Addendum (UCS-840A). Case Title Index/Case Number Court Judge (ifassigned) Relationship to instantcase For parties withoutan attorney, check the"Un-Rep" box and enter the party's phone number and emailin thespace PARTIES: address, provided.If additional space is required, completeand attachthe RJI Addendum (UCS-840A). Un- Parties Attorneys and/or Unrepresented Litigants Issue Joined | Insurance Rep List parties in same order as listed in the For represented parties, provide attorney's name, firm name, address, phone For each defendant, For each defendant, caption and indicate roles (e.g., plaintiff, and email. For unrepresented parties, provide party's address, phone and indicate if issue has indicate insurance defendant; 3rdparty plaintiff, etC.) email. beenjoined. carrier, if applicable. Name: LIBERTY MUTUAL ASHER GROSSMAN, Law Offices ofBurke, & Conway INSURANCE COMPANY Stiefeld,10 Bank Street Suite1200, White Plains,NY E YES O NO Role(s):Plaintiff/Petitioner 10601, 9149978100, wphicourtsefile@libertymutual.com Name: LM GENERAL INSURANCE ASHER GROSSMAN, Law Offices ofBurke, & Conway COMPANY Stiefeld,10 Bank Street Suite1200, White Plains,NY E YES O NO Role(s):Plaintiff/Petitioner 10601, 9149978100, wphicourtsefile@libertymutual.com Name: THOMAS, KENDON 14521 Tuskegee Airman Way, Jamaica, NY 11435 O YES E NO Role(s):Defendant/Respondent Name: AMRO CARE PT, P.C· 2427 Coyle Street, Apt. 2,Brooklyln, NY 11235 O YES E NO Role(s):Defendant/Respondent Name: LAWRENCE CHIROPRACTIC 195-35 HollisAve., Basement, Hollis,NY 11423 DIAGNOSTIC SERVICES O YES E NO Role(s):Defendant/Respondent Name: NORTH SHORE HOME CARE 46-28 243rd Street, Douglaston, NY 11362 SERVICES, INC. O YES O NO Role(s):Defendant/Respondent Name: AVA CUSTOM SUPPLY INC· 3426 Guider Avenue, 1st Floor,Brooklyn, NY 11235 O YES E NO Role(s):Defendant/Respondent Name: OPUS PSYCHOLOGICAL 43-60 Douglaston, New York,NY 11363 SERVICES P.C. O YES E NO Role(s):Defendant/Respondent Name: SI ACUPUNCTURE, PC 3 Dakota Drive, Suite300, Lake Success, NY 11042 O YES E NO Role(s):Defendant/Respondent Name: METRO PAIN SPECIALISTS OLEG RYBAK, THE RYBAK FIRM PLLC, 1810 VOORHIES PROFESSIONAL CORPORATION AVENUE, SUITE 7 , Brooklyn,NY 11235, 718-975-2035, E YES O NO Role(s):Defendant/Respondent orybak@rybakfirm.com I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR PROCEEDINGS, EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION BEEN PREVIOUSLY FILED INTHIS ACTION OR PROCEEDING. Dated: 07/14/2020 ASHER G. GROSSMAN Signature 5310982 ASHER G. GROSSMAN Attorney Registration Number PrintName This form was generated by NYSCEF 2 of 3 FILED: NEW YORK COUNTY CLERK 07/14/2020 02:15 PM INDEX NO. 654092/2019 Caption NYSCEF Rider DOC. Sheet22 NO. RECEIVED NYSCEF: 07/14/2020 Plaintiff(s)/Petitioner(s) VS. KENDON THOMAS, AMRO CARE PT, P.C.,LAWRENCE CHIROPRACTIC DIAGNOSTIC SERVICES, NORTH SHORE HOME CARE SERVICES, INC.,AVA CUSTOM SUPPLY INC.,OPUS PSYCHOLOGICAL SERVICES P.C., SIACUPUNCTURE, PC, METRO PAIN SPECIALISTS PROFESSIONAL CORPORATION, PROSPECT CHIROPRACTIC PLLC, CITIMEDICAL I, PLLC, MAURO CHIROPRACTIC P.C.,HARBOR MEDICAL GROUP PC, ACUTUS RX, LLC, AK GLOBAL SUPPLY CORP. Defendant(s)/Respondent(s) 3 of 3