Preview
2(23
DOCKET NUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET
20Cv/407-185 The Superior-Court
ba
PLAINTIFF(S): JG. MacLellan Concrete Co., Inc. ‘COUNTY [
Worcester
ADDRESS: 180 Phoenix Avenue, Lowell, MA If
DEFENDANT(S): Enfield Builders, Ing. and Westem Surety Company
f
i
ATTORNEY: Edwin L. Hall, Esquire, Holland & Knight LLP (
ADDRESS: 10 St. James Avenue, Boston, MA 02116 ADDRESS: Enfield Builders, ine:, 1654 King Street, Enfield, CT
Westem Surety Company, 333 8, Wabash Ave., Chicago, IL
74
BBO: 667276
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
‘CODE NO. TYPE OF ACTION (specify) TRACK
waked JURY CLAIM BEEN MADE?
A01 Services, Labor and Materials F roves [KX]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.
2}
‘ORT CLAIMS \
(attach additional sheets as necessary) i
f
|A. Documented medical expenses to date
1. Total hospital expenses
2. Total doctor expenses
3. Total chiropractic expenses =
4. Total physical therapy exper
5, Total other expenses (describe below) tec? Subtotal (
'B. Documented lost wages and compensation to date
C. Documented property damages to dated
D. Reasonably anticipated future medical and hospital expenses
ATTEST:
QP EA
E, Reasonably anticipated lost wages
F. Other documented items of damages (describe below)
IG. Briefly describe plaintiffs injury, including the nature and extent of injury:
TOTAL (A-F):$
0! \CT CLAIM:
(attach additional sheets as necessary)
Provide a detailed description of claims(s):
‘Claim by a material supplier for amount owed for concrete delivered to a public construction project in West Boyistdn. TOTAL: $ 126,296.50
Also Claim against a performance bond.
Signature of Attorney/Pro Se Plaintiff: X
ECH__— i! 1 Date: Dec 22, 2020
IRELATED ACTIONS: Please provide the case number, case name, and county of any related actions |pending in the Superior Court.
None. i
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 court-connected dispute resolution'sefvices and discuss with them the
advantages and disadvantages of the various methods of dispute resolution.
Signature of Attorney of Record:
ECLA Date: Dec 22, 2020
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
AC Actions Involving the State/Municipality* ER Equitable Remedies RPProperty
Real
‘AA1 Contract Action involving Commonwealth, 01 Specific Performance of a Contract (A) C01 Land Taking ©
Municipality, MBTA, etc. D02 Reach and Apply ) C02 Zoning Appeal, GL. c. 40 (F)
ABI Tortious Action involving Commonwealth, D3 Injunction ©) C03 Dispute Concerning Title
Municipality, MBTA, etc. 104 Reform/ Cancel Instrument C04 Foreclosure of a Morigage &)
AC1 Real Property, Action involving DOS Equitable Replevin © COS Condominium Lien & Charges ®)
monwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification F) C99 Other Real Property Action °
‘AD1 Equity Action involving Commonweal 007 Imposition of a Trust (A)
Municipality, MBTA, etc. a 08 Minority Shareholders Suit (A) MC Miscellaneous Civil Actions
‘AE1 Administrative Action involving D09 Interference in Contractual Relationship (F)
Commonwealth, Municipality, MBTA.etc. (A) 10 Accounting E18 Foreign Discovery Proceeding ®)
D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus (x)
CN
Contract/Business
Cases. 112 Dissolution of a Partnershiy E22 Lottery Assignment, G.L. c, 10 §28 )
D13 Declaratory Judgment, G.L. ¢.231A (A)
A01 Services, Labor, and Materials «®) D14 Dissolution of a Corporation AB Abuse/Harassment Prevention
A02 Goods Sold and Delivered ) D99 Other Equity Action FF)
‘A03 Commercial Paper © E15 Abuse Prevention Petition, G.L. c. 209A _(X)
‘A04 Employment Contract (F) A Civi i I E21 Protection from Harassment, G.L. ¢. 258E(X)
A06 Insurance Contract ©
A08 Sale or Lease of Real Estate F) PA1 Contract Action involving an -AA
Administrative
Civil Actions
‘A12 Construction Dispute a) Incarcerated Party
14 Interpleader (Fr) PB1 Tortious Action involving an
(A) E02 Appeal from Administrative Agency,
BA1 Governance, Conduct, Internal Incarcerated Party Glo. 3 ”
Affairs of Entities (A) A) E03 Certiorari Action, G.L. ¢.249 §4 &)
BAS Liability of Shareholders, Directors, PC1 Real Property Action involving an E05 Confirmation of Arbitration Awards ®)
Officers, Partners, etc. (a) Incarcerated Party E06 Mass AntitrustAct, G. L. c. 93 §9 (A)
BB1 Shareholder Derivative (A) PD1 Equity Action involving an E07 Mass Antitrust Act, Lc. 93 §8 ®)
BB2 Securities Transactions (a) Incarcerated Party ) E08 Appointment of a Receiver ®)
BC1 Mergers, Consolidations, Sales of PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149
Assets, Issuanceof Debt, Equity, etc. ) Incarcerated Party (F) 329, 29 (A)
D1 Intellectual Property TR Torts E10 Summary Process Appeal ®)
D2 Proprietary Information or Trade E11 Worker's Compensation ®
Secrets (A) B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal ®)
G1 Financial Institutions/Funds (a) Injury/Property Damage E17 Civil Rights Act, G.L. c.12 §11H (a)
BH1 Violation of Antitrust or Trade ®) E24 Appeal from District Court
Regulation Laws (A) B04 Other Negligence - Personal Commitment, G.L. ¢.123 §9(b) *)
‘A99 Other Contract/Business Action - Specify (F) InjuryiProperty Damage ) E25 Pleural Registry (Asbestos cases).
BOS Products A) E94 Forfeiture, G.L. 0265 §56 ®)
B06 Malpractice ledical / Wrongful Death (A) E95 Forfeiture, G.L. c.94C §47 )
B07 Malpractice - Other (a) E99 Other Administrative Action ®)
* Choose this case type if ANY party is the B08 Wrongful Death, G.L. ¢.229 §2A @) 201 Medical Malpractice - Tribunal only,
Commonwealth, a municipality, the MBTA, or any B15 Defamation (A) GL. c. 231 §60B )
other governmental entity UNLESS your case is a B19 Asbestos (A) Z02 Appeal Bond Denial ®
case type listed under Administrative Civil Actions B20 Personal Injury - Slip & Fall ©
(AA). B21 Environmental «) SO Sex Offender Review
B22 Employment Discrimination )
+ Choose this case type if ANY party is ari BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. ¢. 123A §12 ”
incarcerated party, UNLESS your case is a case B99 Other Tortious Action ®) E14 SDP Petition, G.L.c. 123A §9(b) ®
type listed under Administrative Civil Actions (AA)
or is a Prisoner Habeas Corpus case (E97). RC
Restricted
Civil Actions
E19 Sex Offender Registry, G.L. 0.6 §178M )
E27 Minor Seeking Consent, G.L. ¢.112 §12S (x)
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
Bo3 Motor Vehicle Negligence-Personal Injury —F. YES [no
STATEMENT OF DAMAGES PURSUANT TO G.L. 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
2(23 DOCKET NUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET 20Cv/407-185 The Superior-Court ba PLAINTIFF(S): JG. MacLellan Concrete Co., Inc. ‘COUNTY [ Worcester ADDRESS: 180 Phoenix Avenue, Lowell, MA If DEFENDANT(S): Enfield Builders, Ing. and Westem Surety Company f i ATTORNEY: Edwin L. Hall, Esquire, Holland & Knight LLP ( ADDRESS: 10 St. James Avenue, Boston, MA 02116 ADDRESS: Enfield Builders, ine:, 1654 King Street, Enfield, CT Westem Surety Company, 333 8, Wabash Ave., Chicago, IL 74 BBO: 667276 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) ‘CODE NO. TYPE OF ACTION (specify) TRACK waked JURY CLAIM BEEN MADE? A01 Services, Labor and Materials F roves [KX]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. 2} ‘ORT CLAIMS \ (attach additional sheets as necessary) i f |A. Documented medical expenses to date 1. Total hospital expenses 2. Total doctor expenses 3. Total chiropractic expenses = 4. Total physical therapy exper 5, Total other expenses (describe below) tec? Subtotal ( 'B. Documented lost wages and compensation to date C. Documented property damages to dated D. Reasonably anticipated future medical and hospital expenses ATTEST: QP EA E, Reasonably anticipated lost wages F. Other documented items of damages (describe below) IG. Briefly describe plaintiffs injury, including the nature and extent of injury: TOTAL (A-F):$ 0! \CT CLAIM: (attach additional sheets as necessary) Provide a detailed description of claims(s): ‘Claim by a material supplier for amount owed for concrete delivered to a public construction project in West Boyistdn. TOTAL: $ 126,296.50 Also Claim against a performance bond. Signature of Attorney/Pro Se Plaintiff: X ECH__— i! 1 Date: Dec 22, 2020 IRELATED ACTIONS: Please provide the case number, case name, and county of any related actions |pending in the Superior Court. None. i 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 court-connected dispute resolution'sefvices and discuss with them the advantages and disadvantages of the various methods of dispute resolution. Signature of Attorney of Record: ECLA Date: Dec 22, 2020 CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE AC Actions Involving the State/Municipality* ER Equitable Remedies RPProperty Real ‘AA1 Contract Action involving Commonwealth, 01 Specific Performance of a Contract (A) C01 Land Taking © Municipality, MBTA, etc. D02 Reach and Apply ) C02 Zoning Appeal, GL. c. 40 (F) ABI Tortious Action involving Commonwealth, D3 Injunction ©) C03 Dispute Concerning Title Municipality, MBTA, etc. 104 Reform/ Cancel Instrument C04 Foreclosure of a Morigage &) AC1 Real Property, Action involving DOS Equitable Replevin © COS Condominium Lien & Charges ®) monwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification F) C99 Other Real Property Action ° ‘AD1 Equity Action involving Commonweal 007 Imposition of a Trust (A) Municipality, MBTA, etc. a 08 Minority Shareholders Suit (A) MC Miscellaneous Civil Actions ‘AE1 Administrative Action involving D09 Interference in Contractual Relationship (F) Commonwealth, Municipality, MBTA.etc. (A) 10 Accounting E18 Foreign Discovery Proceeding ®) D11 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus (x) CN Contract/Business Cases. 112 Dissolution of a Partnershiy E22 Lottery Assignment, G.L. c, 10 §28 ) D13 Declaratory Judgment, G.L. ¢.231A (A) A01 Services, Labor, and Materials «®) D14 Dissolution of a Corporation AB Abuse/Harassment Prevention A02 Goods Sold and Delivered ) D99 Other Equity Action FF) ‘A03 Commercial Paper © E15 Abuse Prevention Petition, G.L. c. 209A _(X) ‘A04 Employment Contract (F) A Civi i I E21 Protection from Harassment, G.L. ¢. 258E(X) A06 Insurance Contract © A08 Sale or Lease of Real Estate F) PA1 Contract Action involving an -AA Administrative Civil Actions ‘A12 Construction Dispute a) Incarcerated Party 14 Interpleader (Fr) PB1 Tortious Action involving an (A) E02 Appeal from Administrative Agency, BA1 Governance, Conduct, Internal Incarcerated Party Glo. 3 ” Affairs of Entities (A) A) E03 Certiorari Action, G.L. ¢.249 §4 &) BAS Liability of Shareholders, Directors, PC1 Real Property Action involving an E05 Confirmation of Arbitration Awards ®) Officers, Partners, etc. (a) Incarcerated Party E06 Mass AntitrustAct, G. L. c. 93 §9 (A) BB1 Shareholder Derivative (A) PD1 Equity Action involving an E07 Mass Antitrust Act, Lc. 93 §8 ®) BB2 Securities Transactions (a) Incarcerated Party ) E08 Appointment of a Receiver ®) BC1 Mergers, Consolidations, Sales of PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149 Assets, Issuanceof Debt, Equity, etc. ) Incarcerated Party (F) 329, 29 (A) D1 Intellectual Property TR Torts E10 Summary Process Appeal ®) D2 Proprietary Information or Trade E11 Worker's Compensation ® Secrets (A) B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal ®) G1 Financial Institutions/Funds (a) Injury/Property Damage E17 Civil Rights Act, G.L. c.12 §11H (a) BH1 Violation of Antitrust or Trade ®) E24 Appeal from District Court Regulation Laws (A) B04 Other Negligence - Personal Commitment, G.L. ¢.123 §9(b) *) ‘A99 Other Contract/Business Action - Specify (F) InjuryiProperty Damage ) E25 Pleural Registry (Asbestos cases). BOS Products A) E94 Forfeiture, G.L. 0265 §56 ®) B06 Malpractice ledical / Wrongful Death (A) E95 Forfeiture, G.L. c.94C §47 ) B07 Malpractice - Other (a) E99 Other Administrative Action ®) * Choose this case type if ANY party is the B08 Wrongful Death, G.L. ¢.229 §2A @) 201 Medical Malpractice - Tribunal only, Commonwealth, a municipality, the MBTA, or any B15 Defamation (A) GL. c. 231 §60B ) other governmental entity UNLESS your case is a B19 Asbestos (A) Z02 Appeal Bond Denial ® case type listed under Administrative Civil Actions B20 Personal Injury - Slip & Fall © (AA). B21 Environmental «) SO Sex Offender Review B22 Employment Discrimination ) + Choose this case type if ANY party is ari BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. ¢. 123A §12 ” incarcerated party, UNLESS your case is a case B99 Other Tortious Action ®) E14 SDP Petition, G.L.c. 123A §9(b) ® type listed under Administrative Civil Actions (AA) or is a Prisoner Habeas Corpus case (E97). RC Restricted Civil Actions E19 Sex Offender Registry, G.L. 0.6 §178M ) E27 Minor Seeking Consent, G.L. ¢.112 §12S (x) TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? Bo3 Motor Vehicle Negligence-Personal Injury —F. YES [no STATEMENT OF DAMAGES PURSUANT TO G.L. 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.