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DOCKET NUMBER Trial Court of Massachusetts >
CIVIL ACTION COVER SHEET 20 i124 The Superior Court
fi
PLAINTIFF(S): Regina Post COUNTY
Hampshire
ADDRESS: 53 Stephens Street, Chicopee, MA.01020
DEFENDANTIS}: HES of America, Inc,
143 River Road, Hudson, MA 01749-2627
ATTORNEY: ‘Thomas
A, Kokonowski, Esq EricM, Moberg
ADDRESS: ‘Adams & Kokonowski, LLC ADDRESS: 139 Union Road, Wales, MA 01081
46 Main Stree}, Northampton, MA 01060
BBO: ‘
564549
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
BO3 Motor Vehicle Negligence/Personal Injury F XJ Yes [no
‘If “Other” please describe:
‘STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A
The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff counsel relies to determine money damages. For
this form, disregard double or treble damage claims; indicate single damages only.
TORT CLAIMS
{attach additional sheets as necessary)
A. Documented medical expenses to date:
3335.61
1. Total hospital expenses
2. Total doctor expenses WIP SHERE SUPERIOR TO TSSTT ES _|
3. Total chiropractic expenses
4. Total physical therapy expenses eseve
5. Total other expenses (describe belaw)...... assseetesers 1857.
Town of Belchertown, MA Ambulance Services
NOVO 3 2020 ‘Subtotal (A)
|B. Documented lost wages and compensation to date
iC. Documented property damages to dated wee we os
ID, Reasonably anticipated future medical and hospital expenses
IE. Reasonably anticipated lost wa LER KTH
IF. Other documented items of damages (describe below)
G. Briefly describe plaintiffs injury, including the nature and extentof injury:
Plaintiff was in T-Bone type MVA and suffered pain to the back left side of her neck, headache, rt arm pain, low back pain
TOTAL {AF):$ 18505.19.
(attach additional sheets as necessary)
Provide a detailed description of claims(s):
TOTAL: $
| a
Signature of Attorney/Pro Se Plaintiff: X
RELATED ACTIONS: Please provide the case’number, case name, and county of any related actions pending in the Superior Coult.
Date:_7//3 [Dy
/
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 couresonnected dispute resolution services and discuss with them the
advantages and disadvantages of the yargus mshnods-orsagnus resoli
} shot
~
Signature of Attomey of Record: Date: | j
nh
oa
DocuSign Envelope ID: A2D079£0-DDSB-4890-BBEC-6F529649:
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
AC Actions Involving the State/Municipality * ER Equitable Remedies RPProperty
Real
AAI Contract Action involving Commonwealth, D01 Specific Performance of a Contract (A) CO1 Land Taking ©
Municipality, MBTA, ete. 002 Reach and Apply ) C02 Zoning Appeal, G.L.¢. 404.
AB1 Tortious Action involving Commonwealth, DOS Injunction ) C03 Dispute Conceming Title
Municipality, MBTA, etc. 104 Reform! Cancel Instrument C04 Foreclosure of a Mortgage &)
AC! Real Proparty Action involving DOS Equitable Replevin ) C05 Condominium Lien & Charges oO
‘Commonwealth, Municipality, MBTA etc. (A) 106 Contribution or Indemnification (F) C99 Other Real Property Action
ADT Eauly Acton invohing Commenwecth DQ7 Imposition of a Trust A)
1D08 Minority Shareholders Suit -MC
Miscellaneous
Civil Actions
AE pammneuate pole velvng DO9 Interference in Contractyal Relationship )
Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting £18 Foreign Discovery Proceeding &)
D11 Enforcementof Restrictive Covenant (F) £97 Prisoner Habeas Corpus
SN
ContractBusiness
Cases Dt2 Dissolution of a Partnership E22 Lottery Assignment, G.L. c, 10 §28 ®
D13 Declaratory Judgment, G.L.c.231A @)
AO1 Services, Labor, and Materials ©) 1D14 Dissolution of a Corporation (F) AB Abuse/Harassment Prevention
A02 Goods Sold and Delivered ) 099 Other Equity Action f)
‘A03 Commercial
Paper ©) E15 Abuse Prevention Petition, G.L.c. 209A _(X)
‘A04 Employment Contract ) PA Givil Actions Involving Incarcerated
Party. t £21 Protection from Harassment, GL. c, 258E(X)
0G Insurance Contract )
A08 Sale or Lease of Real Estate _AA
Administrative
Civil Actions:
At2 Construction Dispute @) PA1 Contract Action involving an
A14 Interpieader F} Incarcerated Party @) 02 Appeal from Administrative Agency,
BA1 Governance, Conduct, Internal PBI Tortious Action involvingan GL c 30a «)
Affairsof Entities (A) Incarcerated Party A E03 Certiorari Action, G.L. ¢.249§4
BA3 Liability of Shareholders, Directors, PC1 Real Property Action involving en E05 Confirmation of Arbitration Awards
Officers, Partners, etc. @)
Incarcerated Party (F) E06 Mass Antitrust Act, G. L. c. 93 §9 @
BB1 Shareholder Derivative (a) PD1 Equity Action involving an E07 Mass AntitrustAct, G, L. c. 93 §8 ~
BB2 Securities Transactions @ Incarcerated Party f) E08 Appointment of a Receiver
BC1 Mergers, Consolidations, Salesof PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. ¢. 149
Assets, issuance of Debt, Equity, etc. a Incarcerated Party F)
$829, A
B01 Intellectual Proper (A) E10 Summary Process Appeal we
D2 Proprietary Infarmation or Trade IB
Torts E11 Worker's Compensation &)
(A) 1803 Motor Vehicle Negligence - Personal E16 Auto Surcharge peal «
G1 Financial institutions/Funds a E17 Givi Rights Act, G.L. ¢.12 §11H a)
8H1 Violation of Antitrust or Trada Injury/Property Damage *) E24 Appeal from District Court
Regulation Laws @ B04 Other Negligence - Personal Commitment, G.L 123 §9(b) &)
A99 Cther Contract/Business Action - Specify (F) uy/Property Damage F) E25 Pleural Registry cases)
B05 Products Liability @) £94 Forfeiture, G.L. c265 §56
BO6 Malpractice - Medical / Wrongful Death a) £95 Forfeiture, G.L. ¢.94C §47 €)
‘B07 Malpractice - Other @) £99 Other Administrative Action o
* Choose this casa type if ANY party is the B08 Wrongful Death, G.L. ¢.228 §2A @) 201 Medical Malpractice - Tribunal only,
Commonwealth, a municipality, the MBTA, or any B15 Defamation @ GL.
c. 231 §608 )
other govemmental entity UNLESS your case Is a B19 Asbestos ” 202 Appeal Bond Denial ®)
case type listed under Administrative Civil Actions B20 Personal Injury- Stip & Fall (F)
(A). B21 Environmental )
B22 Employment Discrimination F)
SO Sox Offonder Roview
+ Choose this case type if ANY party is an BE! Fraud, Business Torts, etc. @ E12 SDP Commitment, G.L. c. 123A §12 ®
incarcerated party, UNLESS your case is a case B99 Other Tortious Action (F) E14 SDP Petition, G.L. c. 123A §9(b) ”
type listed under Administrative Civil Actions (AA)
or is a Prisoner Habeas Corpus case (E97). BG
Restricted
Civil Actions
E19 Sex Offender Registy, GL. 6.6 §178M ©
E27 Minor Seeking Consent, G.L c.112 §125 (X)
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. ‘TYPE OF ACTION (spectty) TRACK HAS A JURY CLAIM BEEN MADE?
BOo3 Motor Vehicle Negligence-Persanal Injury —E Rl ves [no
STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A
DUTY OF THE PLAINTIFF - The plaintiff shall set forth, an the face of the civil action cover sheet (or attach additional sheets as necessary),
statement specifying the facts on which the plaintiff relies to determine maney damages, A copy of such civil action cover sheet, including the
statement as to the damages, shall be served with the complaint. A clerk-magistrate shall not accept for fillng a complaint, except as
otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or pro Se party.
DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may
file with his/her answer a statement specifying the potential damages which may result if the plaintiff prevails.
ACIVIL-COVER SHEET MUST BE FILED WITH EACH COMPLAINT.
FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY
MAY RESULT IN DISMISSAL OF THIS ACTION.
Preview
oo DOCKET NUMBER Trial Court of Massachusetts > CIVIL ACTION COVER SHEET 20 i124 The Superior Court fi PLAINTIFF(S): Regina Post COUNTY Hampshire ADDRESS: 53 Stephens Street, Chicopee, MA.01020 DEFENDANTIS}: HES of America, Inc, 143 River Road, Hudson, MA 01749-2627 ATTORNEY: ‘Thomas A, Kokonowski, Esq EricM, Moberg ADDRESS: ‘Adams & Kokonowski, LLC ADDRESS: 139 Union Road, Wales, MA 01081 46 Main Stree}, Northampton, MA 01060 BBO: ‘ 564549 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? BO3 Motor Vehicle Negligence/Personal Injury F XJ Yes [no ‘If “Other” please describe: ‘STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only. TORT CLAIMS {attach additional sheets as necessary) A. Documented medical expenses to date: 3335.61 1. Total hospital expenses 2. Total doctor expenses WIP SHERE SUPERIOR TO TSSTT ES _| 3. Total chiropractic expenses 4. Total physical therapy expenses eseve 5. Total other expenses (describe belaw)...... assseetesers 1857. Town of Belchertown, MA Ambulance Services NOVO 3 2020 ‘Subtotal (A) |B. Documented lost wages and compensation to date iC. Documented property damages to dated wee we os ID, Reasonably anticipated future medical and hospital expenses IE. Reasonably anticipated lost wa LER KTH IF. Other documented items of damages (describe below) G. Briefly describe plaintiffs injury, including the nature and extentof injury: Plaintiff was in T-Bone type MVA and suffered pain to the back left side of her neck, headache, rt arm pain, low back pain TOTAL {AF):$ 18505.19. (attach additional sheets as necessary) Provide a detailed description of claims(s): TOTAL: $ | a Signature of Attorney/Pro Se Plaintiff: X RELATED ACTIONS: Please provide the case’number, case name, and county of any related actions pending in the Superior Coult. Date:_7//3 [Dy / 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 couresonnected dispute resolution services and discuss with them the advantages and disadvantages of the yargus mshnods-orsagnus resoli } shot ~ Signature of Attomey of Record: Date: | j nh oa DocuSign Envelope ID: A2D079£0-DDSB-4890-BBEC-6F529649: CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE AC Actions Involving the State/Municipality * ER Equitable Remedies RPProperty Real AAI Contract Action involving Commonwealth, D01 Specific Performance of a Contract (A) CO1 Land Taking © Municipality, MBTA, ete. 002 Reach and Apply ) C02 Zoning Appeal, G.L.¢. 404. AB1 Tortious Action involving Commonwealth, DOS Injunction ) C03 Dispute Conceming Title Municipality, MBTA, etc. 104 Reform! Cancel Instrument C04 Foreclosure of a Mortgage &) AC! Real Proparty Action involving DOS Equitable Replevin ) C05 Condominium Lien & Charges oO ‘Commonwealth, Municipality, MBTA etc. (A) 106 Contribution or Indemnification (F) C99 Other Real Property Action ADT Eauly Acton invohing Commenwecth DQ7 Imposition of a Trust A) 1D08 Minority Shareholders Suit -MC Miscellaneous Civil Actions AE pammneuate pole velvng DO9 Interference in Contractyal Relationship ) Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting £18 Foreign Discovery Proceeding &) D11 Enforcementof Restrictive Covenant (F) £97 Prisoner Habeas Corpus SN ContractBusiness Cases Dt2 Dissolution of a Partnership E22 Lottery Assignment, G.L. c, 10 §28 ® D13 Declaratory Judgment, G.L.c.231A @) AO1 Services, Labor, and Materials ©) 1D14 Dissolution of a Corporation (F) AB Abuse/Harassment Prevention A02 Goods Sold and Delivered ) 099 Other Equity Action f) ‘A03 Commercial Paper ©) E15 Abuse Prevention Petition, G.L.c. 209A _(X) ‘A04 Employment Contract ) PA Givil Actions Involving Incarcerated Party. t £21 Protection from Harassment, GL. c, 258E(X) 0G Insurance Contract ) A08 Sale or Lease of Real Estate _AA Administrative Civil Actions: At2 Construction Dispute @) PA1 Contract Action involving an A14 Interpieader F} Incarcerated Party @) 02 Appeal from Administrative Agency, BA1 Governance, Conduct, Internal PBI Tortious Action involvingan GL c 30a «) Affairsof Entities (A) Incarcerated Party A E03 Certiorari Action, G.L. ¢.249§4 BA3 Liability of Shareholders, Directors, PC1 Real Property Action involving en E05 Confirmation of Arbitration Awards Officers, Partners, etc. @) Incarcerated Party (F) E06 Mass Antitrust Act, G. L. c. 93 §9 @ BB1 Shareholder Derivative (a) PD1 Equity Action involving an E07 Mass AntitrustAct, G, L. c. 93 §8 ~ BB2 Securities Transactions @ Incarcerated Party f) E08 Appointment of a Receiver BC1 Mergers, Consolidations, Salesof PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. ¢. 149 Assets, issuance of Debt, Equity, etc. a Incarcerated Party F) $829, A B01 Intellectual Proper (A) E10 Summary Process Appeal we D2 Proprietary Infarmation or Trade IB Torts E11 Worker's Compensation &) (A) 1803 Motor Vehicle Negligence - Personal E16 Auto Surcharge peal « G1 Financial institutions/Funds a E17 Givi Rights Act, G.L. ¢.12 §11H a) 8H1 Violation of Antitrust or Trada Injury/Property Damage *) E24 Appeal from District Court Regulation Laws @ B04 Other Negligence - Personal Commitment, G.L 123 §9(b) &) A99 Cther Contract/Business Action - Specify (F) uy/Property Damage F) E25 Pleural Registry cases) B05 Products Liability @) £94 Forfeiture, G.L. c265 §56 BO6 Malpractice - Medical / Wrongful Death a) £95 Forfeiture, G.L. ¢.94C §47 €) ‘B07 Malpractice - Other @) £99 Other Administrative Action o * Choose this casa type if ANY party is the B08 Wrongful Death, G.L. ¢.228 §2A @) 201 Medical Malpractice - Tribunal only, Commonwealth, a municipality, the MBTA, or any B15 Defamation @ GL. c. 231 §608 ) other govemmental entity UNLESS your case Is a B19 Asbestos ” 202 Appeal Bond Denial ®) case type listed under Administrative Civil Actions B20 Personal Injury- Stip & Fall (F) (A). B21 Environmental ) B22 Employment Discrimination F) SO Sox Offonder Roview + Choose this case type if ANY party is an BE! Fraud, Business Torts, etc. @ E12 SDP Commitment, G.L. c. 123A §12 ® incarcerated party, UNLESS your case is a case B99 Other Tortious Action (F) E14 SDP Petition, G.L. c. 123A §9(b) ” type listed under Administrative Civil Actions (AA) or is a Prisoner Habeas Corpus case (E97). BG Restricted Civil Actions E19 Sex Offender Registy, GL. 6.6 §178M © E27 Minor Seeking Consent, G.L c.112 §125 (X) TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. ‘TYPE OF ACTION (spectty) TRACK HAS A JURY CLAIM BEEN MADE? BOo3 Motor Vehicle Negligence-Persanal Injury —E Rl ves [no STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A DUTY OF THE PLAINTIFF - The plaintiff shall set forth, an the face of the civil action cover sheet (or attach additional sheets as necessary), statement specifying the facts on which the plaintiff relies to determine maney damages, A copy of such civil action cover sheet, including the statement as to the damages, shall be served with the complaint. A clerk-magistrate shall not accept for fillng a complaint, except as otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or pro Se party. DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may file with his/her answer a statement specifying the potential damages which may result if the plaintiff prevails. ACIVIL-COVER SHEET MUST BE FILED WITH EACH COMPLAINT. FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY MAY RESULT IN DISMISSAL OF THIS ACTION.