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Filing # 113712292 E-Filed 09/21/2020 04:44:52 PM
IN THE CIRCUIT COURT OF THE
FIFTEENTH JUDICIAL CIRCUIT IN AND
FOR PALM BEACH COUNTY, FLORIDA
CIRCUIT CIVIL DIVISION
CASE NO.: 50-2020-CA-007743 (AN)
JUSTINO VEGA PENA and JUSTIN
WILLIE VEGA,
Plaintiff,
v.
SONY JOSEPH and HL UNIVERSAL, INC.,
a Florida Profit Corporation,
Defendants.
/
DEFENDANTS’ NOTICE OF CE OF MEDICARE INTERROGATORIES TO
P _ JUSTINO VEGA PENA
Pursuant to the Florida Rules of Civil Procedure, Defendants’ hereby file this Notice of
Service of Medicare Interrogatories to Plaintiff, JUSTINO VEGA PENA on September 21, 2020.
WE HEREBY CERTIFY that we electronically filed the foregoing with the Clerk of the
Court by using the Florida Courts E-Filing Portal which will send a Notice of Electronic Filing to:
Carlos Jimenez, Esq., and Scott Goldstein, Esq., CARLOS J. JIMENEZ, P.L., 1880 North Congress
Avenue, Suite 315, Boynton Beach, FL 33426, Counsel for Plaintiff, eService@247Injurylaw.com;
by e-mail on September 21, 2020.
LEWIS BRISBOIS BISGAARD & SMITH, LLP
Attorneys for Defendants
110 SE 6" Street, Suite 2600
Fort Lauderdale, FL 33301
(954)728-1280
(954)728-1282 fax
Jeffrey. Mowers@LewisBrisbois.com
Ellise Silverberg@LewisBrisbois.com
Ftlemaildesig@LewisBrisbois.com
BY: _/s/Jeffrey A. Mowers
JEFFREY A. MOWERS
FBN 508240
4843-1001-0828.1
*** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 09/21/2020 04:44:52 PM ***CASE NO.: 50-2020-CA-007743 (AN)
DEFENDANTS’ MEDICARE INTERROGATORIES TO
PLAINTIFF, JUSTINO VEGA PENA
1. What is the name and address of the person answering these interrogatories, and, if
applicable, the person’s official position or relationship with the party to whom the
interrogatories are directed?
2. List all former names and when you were known by those names. State all addresses where
you have lived for the past 10 years, the dates you have lived at each address, your Social
Security number, your date of birth and your gender.
3. Are you presently receiving, or have you at any time since the date of the subject incident
received, Medicare, Medicaid, Social Security Disability (“SSD”) and/or Supplemental
Security Income (“SSI”) benefits? If yes, please state your Medicare Health Insurance Claim
Number (HICN) and any other applicable claim or matter reference number(s), as well as the
corresponding entitlement date(s).
4. Ifyou answer to Question 3 above is yes, please state: (a) the nature/type of benefits received
(i.e. Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D, Medicaid, SSD,
and or SSI); (b) the cause, basis or reason for each/any of those benefits; (c) the date(s)
each/any of those benefits were received; and (d) the amount received for each/any of those
benefits, per date.
5. If you answer to Question 3 above is yes, please also state what is your current status as a
Medicare, Medicaid, Social Security Disability and/or Supplemental Security Income
recipient.
24. If not currently receiving SSD/SSI, has a claim or request for hearing for SSD/SSI benefits
been filed? If yes, please list all dates of application and date of last denial.
4843-1001-0828.1 2CASE NO.: 50-2020-CA-007743 (AN)
Ihave read the foregoing Answers to Interrogatories and do swear that they are true and correct
of the best of my knowledge, information, and belief.
JUSTINO VEGA PENA
STATE OF FLORIDA
COUNTY OF
BEFORE ME, the undersigned authority, personally appeared JUSTINO VEGA PENA after
being first duly sworn, deposes and says that he/she has read the foregoing Answers to
Interrogatories and the same are true and correct and he/she signed his/her name thereto for the
purposes therein expressed.
Witness my Hand and Official Seal at. , this
day of , 2020.
Notary Public, State of Florida
My Commission expires:
NOTARY - PLEASE CHECK APPROPRIATE BOX:
Personally known to me; or
Produced as identification:
Type of ID.:
4843-1001-0828.1 3
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Filing # 113712292 E-Filed 09/21/2020 04:44:52 PM IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT IN AND FOR PALM BEACH COUNTY, FLORIDA CIRCUIT CIVIL DIVISION CASE NO.: 50-2020-CA-007743 (AN) JUSTINO VEGA PENA and JUSTIN WILLIE VEGA, Plaintiff, v. SONY JOSEPH and HL UNIVERSAL, INC., a Florida Profit Corporation, Defendants. / DEFENDANTS’ NOTICE OF CE OF MEDICARE INTERROGATORIES TO P _ JUSTINO VEGA PENA Pursuant to the Florida Rules of Civil Procedure, Defendants’ hereby file this Notice of Service of Medicare Interrogatories to Plaintiff, JUSTINO VEGA PENA on September 21, 2020. WE HEREBY CERTIFY that we electronically filed the foregoing with the Clerk of the Court by using the Florida Courts E-Filing Portal which will send a Notice of Electronic Filing to: Carlos Jimenez, Esq., and Scott Goldstein, Esq., CARLOS J. JIMENEZ, P.L., 1880 North Congress Avenue, Suite 315, Boynton Beach, FL 33426, Counsel for Plaintiff, eService@247Injurylaw.com; by e-mail on September 21, 2020. LEWIS BRISBOIS BISGAARD & SMITH, LLP Attorneys for Defendants 110 SE 6" Street, Suite 2600 Fort Lauderdale, FL 33301 (954)728-1280 (954)728-1282 fax Jeffrey. Mowers@LewisBrisbois.com Ellise Silverberg@LewisBrisbois.com Ftlemaildesig@LewisBrisbois.com BY: _/s/Jeffrey A. Mowers JEFFREY A. MOWERS FBN 508240 4843-1001-0828.1 *** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 09/21/2020 04:44:52 PM ***CASE NO.: 50-2020-CA-007743 (AN) DEFENDANTS’ MEDICARE INTERROGATORIES TO PLAINTIFF, JUSTINO VEGA PENA 1. What is the name and address of the person answering these interrogatories, and, if applicable, the person’s official position or relationship with the party to whom the interrogatories are directed? 2. List all former names and when you were known by those names. State all addresses where you have lived for the past 10 years, the dates you have lived at each address, your Social Security number, your date of birth and your gender. 3. Are you presently receiving, or have you at any time since the date of the subject incident received, Medicare, Medicaid, Social Security Disability (“SSD”) and/or Supplemental Security Income (“SSI”) benefits? If yes, please state your Medicare Health Insurance Claim Number (HICN) and any other applicable claim or matter reference number(s), as well as the corresponding entitlement date(s). 4. Ifyou answer to Question 3 above is yes, please state: (a) the nature/type of benefits received (i.e. Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D, Medicaid, SSD, and or SSI); (b) the cause, basis or reason for each/any of those benefits; (c) the date(s) each/any of those benefits were received; and (d) the amount received for each/any of those benefits, per date. 5. If you answer to Question 3 above is yes, please also state what is your current status as a Medicare, Medicaid, Social Security Disability and/or Supplemental Security Income recipient. 24. If not currently receiving SSD/SSI, has a claim or request for hearing for SSD/SSI benefits been filed? If yes, please list all dates of application and date of last denial. 4843-1001-0828.1 2CASE NO.: 50-2020-CA-007743 (AN) Ihave read the foregoing Answers to Interrogatories and do swear that they are true and correct of the best of my knowledge, information, and belief. JUSTINO VEGA PENA STATE OF FLORIDA COUNTY OF BEFORE ME, the undersigned authority, personally appeared JUSTINO VEGA PENA after being first duly sworn, deposes and says that he/she has read the foregoing Answers to Interrogatories and the same are true and correct and he/she signed his/her name thereto for the purposes therein expressed. Witness my Hand and Official Seal at. , this day of , 2020. Notary Public, State of Florida My Commission expires: NOTARY - PLEASE CHECK APPROPRIATE BOX: Personally known to me; or Produced as identification: Type of ID.: 4843-1001-0828.1 3