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CIVIL ACTION COVER SHEET ye. Trial Court of Massachusetts
/ 7- SI / 2 The Superior Court
PLAINTIFF(S): dustin Urban COUNTY
ADDRESS: 16 Dartmouth Drive Middlesex
Billerica, MA 01821 DEFENDANT(S): Keith Weston
Interstate Elecrical Services Corp.
ATTORNEY: Richard S. McLaughlin
ADDRESS: 6 Edgerly Place ADDRESS: 12 Westgate Road, Billerica, MA 01821
Boston, MA 0216 70 Treble Cove Road, Billerica, MA 01821
BBO: 550424
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
B03 Motor Vehicle Negligence - Personal Injury F lyYes [no
“if “Other” please describe:
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 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 dal
1. Total hospital expenses
2. Total doctor expenses
3. Total chiropractic expenses
4, Total physical therapy expense:
5. Total other expenses (describe below)
312,607.36
25,000.00
B. Documented lost wages and compensation to date
'C. Documented property damages to dated ..
D. Reasonably anticipated future medical and hospital expenses . aa aun
E. Reasonably anticipated lost wages ....
F, Other documented items of damages (describe below)
PPOHHH ABHBHAH
|G. Briefly describe plaintiff's injury, including the nature and extent of injury:
TOTAL (A-F):$ 358,642.29
CONTRACT CLAIMS
(attach additional sheets as necessary)
Provide a detailed description of claims(s):
TOTAL: $
Signature of Attorney/Pro Se Plaintiff: X Date: March 15, 2017
IRELATED 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 ctients with informatign about court-connected dispute resolution services and discuss with them the
advantages and disadvantages of the various methods of'dispute resol mt
Signature of Attorney of Record: X - Date: March 15, 2017
CcCIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
ER Equitable Remedies
\C Actions Involving the ipality* . BP Real Property
AA1 Contract Action involving Commonwealth, 01 Specific Performance of a Contract (A) C04 Land Taking F)
Municipality, MBTA, etc. @ 02 Reach and Apply () C02 Zoning Appeal, G.L. c. 408 ®
AB1 Tortious Action involving Commonwealth, 08 Injunction ) C03 Dispute Concerning Title ©)
Municipality, MBTA, etc. 0) 04 Reform/ Cancel instrument () C04 Foreclosure of a Mortgage ©
ACI Real Property Action involvi 05 Equitable Replevin () C05 Condominium Lien & Charges ~
Commeonvreatn, Municipality, MBTA et. (A) DOS Contribution or Indemnification ©) €99 Other Real Property Action )
AD1 Equity Action involving Commonwealth, 07 Imposition of a Trust @)
Municipality, MBTA, etc. @) 08 Minority Shareholder's Suit @ MC Miscellaneous Civil Actions
AE1 Administrative Action involving DOS Interference in Contractual Relationship (F)
‘Commonwealth, Municipality, MBTA.etc. (A) D10 Accounting «) E18 Foreign Discovery Proceeding ~
D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus «
CN Contract/Business Cases D12 Dissolution of a Partnership ©) £22 Lottery Assignment, Gl.c.10§28 (X)
13 Declaratory Judgment, G.L.¢.231A (A)
01 Services, Labor, and Materials ©) 14 Dissolution of a Corporation © AB Abuse/Harassment Prevention
‘A02 Goods Sold and Delivered ©) D99 Other Equity Action )
‘A03 Commercial Paper ©) E15 Abuse Prevention Petition, G.L. ¢. 209A _(X)
A04 Employment Contract ©) Civil Actions Inv rated Party t £21 Protection from Harassment, G.L. e. 258&(X)
‘AQ6 Insurance Contract (F)
“ Coctuchos Diente Estate a PAM Contract Action involving an Administra
At4 Interpleader ©) pay maniverated Party “” E02 Appeal from Administrative Agency,
BA1 Governance, Conduct, Internal 81 Tortious Action involving an G.L.c.30A o
Affairs of Entities (A) pct Incarcerated Party oli (a) E03 Certiorari Action, G.L. 6.249 §4 ©
BAS Liability of Shareholders, Directors, ‘C1 Real Property Action involving an E05 Confirmation of Arbitration Awards ®
Officers, Partners, etc. A) Incarcerated Party _ ) E08 Mass Antitrust Act, G. L. c. 93 §9 A)
BB1 Shareholder Derivative (A) PD1 Equity Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8 ”
BB2 Securities Transactions (A) Incarcerated Party © E08 Appointment of a Receiver oo
8C1 Mergers, Consolidations, Sales of PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149
Assets, Issuance of Debt, Equity, etc. (A) Incarcerated Party *) §§29, 298 (a)
801 Intellectual Property @) E10 Summary Process Appeal ~
802 Proprietary Information or Trade TRTorts E11 Worker's Compensation ®
Secrets “ : : E16 Auto Surcharge Appeal ©
G1 Financial Institutions/Funds (A) 803 Motor Vehicle Negligence - Personal E17 Civil Rights Act, G.L. c.12 §11H (a)
BH1 Violation of Antitrust or Trade Injury/Property Damage ° E24 Appeal from District Court
Regulation Laws (a) 504 Other Negligence - Personal ‘Commitment, G.L. ¢.123 §9(b) ~
‘A99 Other Contract/Business Action - Specify (F) Injury/Property Damage (Fy E25 Pleural Registry (Asbestos cases)
BOS Products Liability — (A) E94 Forfeiture, G.L, c265 §56 ~
B06 Malpractice - Medical / Wrongful Death (A) Bes Foriire, GL, e940 647 ©
. ; ; 807 Malpractice - Other “ £99 Other Administrative Action «
* Choose this case type if ANY party is the B08 Wrongful Death, G.L. c.229 §2A ) 201 Medical Malpractice - Tribunal only,
‘Commonwealth, a municipality, the MBTA, or any 815 Defamation (a) Se 231 geo ‘6
other governmental entity UNLESS your case is a B19 Asbestos (A) 202 Appeal Bond Denial *)
case type listed under Administrative Civil Actions 820 Personal Injury - Slip & Fall (6)
(aa). 821 Environmental ©) $0 Sex Offender Review
822 Employment Discrimination @)
+ Choose this case type if ANY party is an 8E1 Fraud, Business Torts, etc. @) .
incarcerated party, UNLESS your case is a case 889 Other Tortious Action (). ESOP Pater Le TAS «8S
type listed under Administrative Civil Actions (AA) —
of ls a Prisoner Habeas Corpus case (E97). RC Restricted Civil Actions
E19 Sex Offender Registry, G.L.c.6 §178M _(X)
E27 Minor Seeking Consent, GL. c.112 §12S (X)
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
B03 Motor Vehicle Negligence-Personal Injury E (no
STATEMENT OF DAMAGES PURSUANT TO GLL. c. 212, § 3A
DUTY OF THE PLAINTIFF - The plaintiff shall set forth, on the face of the civil action cover sheet (or attach additional sheets as necessary), a
statement specifying the facts on which the plaintiff relies to determine money 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 filing 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.
A CIVIL 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
o Zz CIVIL ACTION COVER SHEET ye. Trial Court of Massachusetts / 7- SI / 2 The Superior Court PLAINTIFF(S): dustin Urban COUNTY ADDRESS: 16 Dartmouth Drive Middlesex Billerica, MA 01821 DEFENDANT(S): Keith Weston Interstate Elecrical Services Corp. ATTORNEY: Richard S. McLaughlin ADDRESS: 6 Edgerly Place ADDRESS: 12 Westgate Road, Billerica, MA 01821 Boston, MA 0216 70 Treble Cove Road, Billerica, MA 01821 BBO: 550424 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? B03 Motor Vehicle Negligence - Personal Injury F lyYes [no “if “Other” please describe: 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 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 dal 1. Total hospital expenses 2. Total doctor expenses 3. Total chiropractic expenses 4, Total physical therapy expense: 5. Total other expenses (describe below) 312,607.36 25,000.00 B. Documented lost wages and compensation to date 'C. Documented property damages to dated .. D. Reasonably anticipated future medical and hospital expenses . aa aun E. Reasonably anticipated lost wages .... F, Other documented items of damages (describe below) PPOHHH ABHBHAH |G. Briefly describe plaintiff's injury, including the nature and extent of injury: TOTAL (A-F):$ 358,642.29 CONTRACT CLAIMS (attach additional sheets as necessary) Provide a detailed description of claims(s): TOTAL: $ Signature of Attorney/Pro Se Plaintiff: X Date: March 15, 2017 IRELATED 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 ctients with informatign about court-connected dispute resolution services and discuss with them the advantages and disadvantages of the various methods of'dispute resol mt Signature of Attorney of Record: X - Date: March 15, 2017 CcCIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE ER Equitable Remedies \C Actions Involving the ipality* . BP Real Property AA1 Contract Action involving Commonwealth, 01 Specific Performance of a Contract (A) C04 Land Taking F) Municipality, MBTA, etc. @ 02 Reach and Apply () C02 Zoning Appeal, G.L. c. 408 ® AB1 Tortious Action involving Commonwealth, 08 Injunction ) C03 Dispute Concerning Title ©) Municipality, MBTA, etc. 0) 04 Reform/ Cancel instrument () C04 Foreclosure of a Mortgage © ACI Real Property Action involvi 05 Equitable Replevin () C05 Condominium Lien & Charges ~ Commeonvreatn, Municipality, MBTA et. (A) DOS Contribution or Indemnification ©) €99 Other Real Property Action ) AD1 Equity Action involving Commonwealth, 07 Imposition of a Trust @) Municipality, MBTA, etc. @) 08 Minority Shareholder's Suit @ MC Miscellaneous Civil Actions AE1 Administrative Action involving DOS Interference in Contractual Relationship (F) ‘Commonwealth, Municipality, MBTA.etc. (A) D10 Accounting «) E18 Foreign Discovery Proceeding ~ D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus « CN Contract/Business Cases D12 Dissolution of a Partnership ©) £22 Lottery Assignment, Gl.c.10§28 (X) 13 Declaratory Judgment, G.L.¢.231A (A) 01 Services, Labor, and Materials ©) 14 Dissolution of a Corporation © AB Abuse/Harassment Prevention ‘A02 Goods Sold and Delivered ©) D99 Other Equity Action ) ‘A03 Commercial Paper ©) E15 Abuse Prevention Petition, G.L. ¢. 209A _(X) A04 Employment Contract ©) Civil Actions Inv rated Party t £21 Protection from Harassment, G.L. e. 258&(X) ‘AQ6 Insurance Contract (F) “ Coctuchos Diente Estate a PAM Contract Action involving an Administra At4 Interpleader ©) pay maniverated Party “” E02 Appeal from Administrative Agency, BA1 Governance, Conduct, Internal 81 Tortious Action involving an G.L.c.30A o Affairs of Entities (A) pct Incarcerated Party oli (a) E03 Certiorari Action, G.L. 6.249 §4 © BAS Liability of Shareholders, Directors, ‘C1 Real Property Action involving an E05 Confirmation of Arbitration Awards ® Officers, Partners, etc. A) Incarcerated Party _ ) E08 Mass Antitrust Act, G. L. c. 93 §9 A) BB1 Shareholder Derivative (A) PD1 Equity Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8 ” BB2 Securities Transactions (A) Incarcerated Party © E08 Appointment of a Receiver oo 8C1 Mergers, Consolidations, Sales of PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149 Assets, Issuance of Debt, Equity, etc. (A) Incarcerated Party *) §§29, 298 (a) 801 Intellectual Property @) E10 Summary Process Appeal ~ 802 Proprietary Information or Trade TRTorts E11 Worker's Compensation ® Secrets “ : : E16 Auto Surcharge Appeal © G1 Financial Institutions/Funds (A) 803 Motor Vehicle Negligence - Personal E17 Civil Rights Act, G.L. c.12 §11H (a) BH1 Violation of Antitrust or Trade Injury/Property Damage ° E24 Appeal from District Court Regulation Laws (a) 504 Other Negligence - Personal ‘Commitment, G.L. ¢.123 §9(b) ~ ‘A99 Other Contract/Business Action - Specify (F) Injury/Property Damage (Fy E25 Pleural Registry (Asbestos cases) BOS Products Liability — (A) E94 Forfeiture, G.L, c265 §56 ~ B06 Malpractice - Medical / Wrongful Death (A) Bes Foriire, GL, e940 647 © . ; ; 807 Malpractice - Other “ £99 Other Administrative Action « * Choose this case type if ANY party is the B08 Wrongful Death, G.L. c.229 §2A ) 201 Medical Malpractice - Tribunal only, ‘Commonwealth, a municipality, the MBTA, or any 815 Defamation (a) Se 231 geo ‘6 other governmental entity UNLESS your case is a B19 Asbestos (A) 202 Appeal Bond Denial *) case type listed under Administrative Civil Actions 820 Personal Injury - Slip & Fall (6) (aa). 821 Environmental ©) $0 Sex Offender Review 822 Employment Discrimination @) + Choose this case type if ANY party is an 8E1 Fraud, Business Torts, etc. @) . incarcerated party, UNLESS your case is a case 889 Other Tortious Action (). ESOP Pater Le TAS «8S type listed under Administrative Civil Actions (AA) — of ls a Prisoner Habeas Corpus case (E97). RC Restricted Civil Actions E19 Sex Offender Registry, G.L.c.6 §178M _(X) E27 Minor Seeking Consent, GL. c.112 §12S (X) TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? B03 Motor Vehicle Negligence-Personal Injury E (no STATEMENT OF DAMAGES PURSUANT TO GLL. c. 212, § 3A DUTY OF THE PLAINTIFF - The plaintiff shall set forth, on the face of the civil action cover sheet (or attach additional sheets as necessary), a statement specifying the facts on which the plaintiff relies to determine money 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 filing 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. A CIVIL COVER SHEET MUST BE FILED WITH EACH COMPLAINT. FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY MAY RESULT IN DISMISSAL OF THIS ACTION.