Preview
FILED: NASSAU COUNTY CLERK 01/17/2019 04:18 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 01/17/2019
REQUEST FOR JUDICIAL INTERVENTION For Court Clerk Use Only:
UCS-840 (7/2012)
IAS Entry Date
Nassau Supreme COURT, COUNTY OF Nassau
Judge Assigned
Index No: 611506/2018 Date Index Issued: 08/24/2018
Enter the complete case caption. Do not use et al or et ano. If more space is required, RJI Date
CAPTION: attach a caption rider sheet.
Dino Bonavita
Plaintiff(s)/Petitioner(s)
-against-
Syed Mujahid Sayeed MD, Precision Surgery Of New York, PC, North Shore University Hospital, Northwell Health
Defendant(s)/Respondent(s)
NATURE OF ACTION OR PROCEEDING: Check ONE box only and specify where indicated.
MATRIMONIAL COMMERCIAL
☐ Contested ☐ Business Entity (including corporations, partnerships, LLCs, etc.)
☐ Contract
NOTE: For all Matrimonial actions where the parties have children under the
age of 18, complete and attach the MATRIMONIAL RJI Addendum. For
Uncontested Matrimonial actions, use RJI form UD-13. ☐ Insurance (where insurer is a party, except arbitration)
☐ UCC (including sales, negotiable instruments)
TORTS
☐ Other Commercial:
☐ Asbestos
NOTE: For Commercial Division assignment requests [22 NYCRR § 202.70(D)],
complete and attach the COMMERCIAL DIV RJI Addendum.
☐ Breast Implant
REAL PROPERTY: How many properties does the application include?
☐ Environmental:
☐ Condemnation
☒ Medical, Dental, or Podiatric Malpractice
☐ Mortgage Foreclosure: ☐ Residential ☐ Commercial
☐ Motor Vehicle Property Address:
NOTE: For Mortgage Foreclosure actions involving a one- to four-family, owner-
☐ Products Liability:
occupied, residential property, or an owner-occupied condominium, complete and
attach the FORECLOSURE RJI Addendum.
☐ Other Negligence:
☐ Tax Certiorari - Section: Block: Lot:
☐ Other Professional Malpractice:
☐ Tax Foreclosure
☐ Other Tort:
☐ Other Real Property:
OTHER MATTERS SPECIAL PROCEEDINGS
☐ Certificate of Incorporation/Dissolution
[see NOTE under Commercial] ☐ CPLR Article 75 (Arbitration)
[see NOTE under Commercial]
☐ Emergency Medical Treatment ☐ CPLR Article 78 (Body or Officer)
☐ Habeas Corpus ☐ Election Law
☐ Local Court Appeal ☐ MHL Article 9.60 (Kendra's Law)
☐ Mechanic's Lien ☐ MHL Article 10 (Sex Offender Confinement-Initial)
☐ Name Change ☐ MHL Article 10 (Sex Offender Confinement-Review)
☐ Pistol Permit Revocation Hearing ☐ MHL Article 81 (Guardianship)
☐ Sale or Finance of Religious/Not-for-Profit Property ☐ Other Mental Hygiene:
☐ Other: ☐ Other Special Proceeding:
STATUS OF ACTION OR PROCEEDING: Answer YES or NO for EVERY question AND enter additional information where indicated.
YES NO
Has a summons and complaint or summons w/notice been filed? ☒ ☐ If yes, date filed:
08/24/2018
Has a summons and complaint or summons w/notice been served? ☒ ☐ If yes, date served:
08/29/2018
Is this action/proceeding being filed post-judgment? ☐ ☒ If yes, judgment date:
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FILED: NASSAU COUNTY CLERK 01/17/2019 04:18 PM INDEX NO. 611506/2018
NATURE
NYSCEF OF NO.
DOC. JUDICIAL
17 INTERVENTION: RECEIVED NYSCEF:
Check ONE box only AND enter additional information where indicated. 01/17/2019
☐ Infant's Compromise
☐ Note of Issue and/or Certificate of Readiness
☐ Notice of Medical, Dental, or Podiatric Malpractice
Date Issue Joined:
☐ Notice of Motion Relief Sought: Return Date:
☐ Notice of Petition Relief Sought: Return Date:
☐ Order to Show Cause Relief Sought: Return Date:
☐ Other Ex Parte Application Relief Sought:
☐ Poor Person Application
☒ Request for Preliminary Conference
☐ Residential Mortgage Foreclosure Settlement Conference
☐ Writ of Habeas Corpus
☐ Other:
RELATED CASES: List any related actions. For Matrimonial actions, include any related criminal and/or Famiy Court cases. If
additional space is required, complete and attach the RJI Addendum. If none, leave blank.
Case Title Index/Case No. Court Judge (if assigned) Relationship to Instant Case
PARTIES: For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail
address in space provided. If additional space is required, complete and attach the RJI Addendum.
Parties: Attorneys and/or Unrepresented Litigants:
List parties in caption order and indicate Issue
Provide attorney name, firm name, business address, phone number and e-
Un- Insurance Carrier(s):
party role(s) (e.g., defendant; 3rd-party Joined
mail address of all attorneys that have appeared in the case. For
Rep plaintiff). unrepresented litigants, provide address, phone number and e-mail address.
(Y/N):
Name: Bonavita, Dino CAITLIN ROBIN, CAITLIN ROBIN AND ASSOCIATES PLLC, 30 Broad St Ste
702 , New York, NY 10004, caitlin@robinandassociates.com
☐ Role(s): Plaintiff/Petitioner
YES
Name: Sayeed, Syed Mujahid THOMAS BENVENUTO, Law Offices of Benvenuto & Slattery, 1800 Northern
Boulevard , Roslyn, NY 11576, 516-775-2236, sbs-law@sbs-law.com
☐ Role(s): Defendant/Respondent
YES
Name: Precision Surgery Of New York, PC
THOMAS BENVENUTO, Law Offices of Benvenuto & Slattery, 1800 Northern
Boulevard , Roslyn, NY 11576, 516-775-2236, sbs-law@sbs-law.com
☐ Role(s): Defendant/Respondent
YES
Name: North Shore University Hospital
Rubin Paterniti Gonzalez Kaufman, LLP, 1225 Franklin Avenue, Suite 200,
Garden City, NY 11530, 5163446376
☐ Role(s): Defendant/Respondent
YES
Name: Northwell Health Rubin Paterniti Gonzalez Kaufman, LLP, 1225 Franklin Avenue, Suite 200,
Garden City, NY 11530, 5163446376
☐ Role(s): Defendant/Respondent
YES
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS NOTED ABOVE, THERE
ARE AND HAVE BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL
INTERVENTION PREVIOUSLY BEEN FILED IN THIS ACTION OR PROCEEDING.
Dated: 01/17/2019 CAITLIN ANNE ROBIN
SIGNATURE
4536017 CAITLIN ANNE ROBIN
ATTORNEY REGISTRATION NUMBER PRINT OR TYPE NAME
This form was generated by NYSCEF
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