Preview
FILED: NEW YORK COUNTY CLERK 06/29/2020 03:22 PM INDEX NO. 162516/2019
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 06/29/2020
The City of New York
JAMES E. JOHNSON LAW DEPARTMENT
Corporation Counsel 100 CHURCH STREET
NEW YORK, NEW YORK 10007
Dear Counsel:
If you would like to have this case considered for possible early settlement by the
Early Intervention Unit of the Tort Division, the following items (as applicable) should be
forwarded to the attention of Millicent Nicholas-Richards via email to mnichola@law.nyc.gov.
IN ALL CASES COPIES OF THE FOLLOWING ITEMS MUST BE PROVIDED:
1. Notice of Claim and Filed Summons & Complaint.
2. Aided Card, if prepared.
3. UF18 - City Involved Accident Report, if prepared.
4. All medical and hospital records, including ambulance call report, first treatment, full
emergency room record, operative and radiology reports, treating physician(s) reports,
physical therapy records, etc.
5. Photographs (duplicates, color or laser copies preferred) of the location and of injuries, if
scarring is claimed.
6. Proof of any special damages claimed.
7. Any other item(s) that you believe pertinent to an early resolution of your case.
8. Social Security number and any other Medicare information – see attached notice
ALLEGED TRIP AND FALL ON A SIDEWALK OR ROADWAY
1. Most recently dated Big Apple map.
2. Any other documents that the plaintiff will rely upon to prove prior written notice.
MOTOR VEHICLE ACCIDENT CASES
1. Police Accident Report.
2. Agency incident/accident report, if prepared.
3. Repair bills and/or estimates.
4. If the accident involves traffic light or stop sign, any documentation that the plaintiff will
rely upon to prove notice.
ALLEGED PREMISES LIABILITY
1. Copies of any documents that plaintiff will rely on to establish ownership of the premises.
2. Prior complaints.
3. Accident/incident reports.
DEPARTMENT OF EDUCATION CASES
1. Accident and/or incident report and attachments, if any.
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2. Custodian reports.
3. Teacher(s) statements/reports.
4. Witness statements.
ALLEGED POLICE MISCONDUCT
1. Any police reports in your possession.
2. Arrest Report, Complaint report, follow-up reports and photographs.
3. Certified copy of the disposition of any criminal proceedings.
4. If entitlement to reimbursement of legal fees is claimed, copies of any bills incurred.
ALLEGED PROPERTY DAMAGE
1. Photographs (duplicates, color or laser copies preferred) depicting the items alleged to have
been damaged, prior and subsequent to the damage.
2. Original purchase receipts, cancelled checks, and/or charge slips for the items alleged to
have been damaged.
3. Appraisals, warranties, etc.
4. Copies of any insurance agreements pertaining to property damages and/or loss.
Please be advised that all of the above materials must be sent in order to have your case considered
for possible early settlement - incomplete cases cannot be considered. Within 30 days after receipt
of the above materials via email, you will be contacted to discuss the case further. Counsel
appearing at the conference must have settlement authority and be prepared to establish liability
and damages. If you have any questions, you may contact Nancy A. Goldbach directly by email to
ngoldbac@law.nyc.gov.
Very truly yours,
Nancy A. Goldbach
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The City of New York
LAW DEPARTMENT
Office of the Corporation Counsel (212) 356-3109 (fax)
medicare@law.nyc.gov
Tort Division
JAMES E. JOHNSON Medicare Compliance and Recovery Unit
Corporation Counsel 100 Church Street, 4th Floor
New York, NY 10007-2668
June 29, 2020
ROBERT DEMBIA, P.C
160 BROADWAY, ROOM 610
NEW YORK, NY 10038
Re: ERNEST WATSON AND ABBY WATSON v.
THE CITY OF NEW YORK; DET. "JOHN"
BRADY, SHIELD NO. 646 AND P.O. RENE
SOTO
Law Dept. File No: 2020-002205
Dear Counselor:
We write to request that you provide us with certain personal identifying information
about each plaintiff you represent in this lawsuit in order for us to determine whether they are a
Medicare recipient(s). Specifically, we need each plaintiff’s date of birth, gender, and Social
Security number or Health Insurance Claim Number (HICN), also known as the Medicare
number. This information will be used by the Law Department to obtain plaintiff’s Medicare
status via a database established by the Centers for Medicare & Medicaid Services ("CMS") for
this purpose.1
Information about a plaintiff’s Medicare status is required by the City in order to comply
with federal Medicare laws. Self-insured liability entities (such as the City of New York) are
considered “primary plans” under the Medicare laws and are, therefore, required to report to
CMS all monetary recoveries obtained by Medicare-eligible plaintiffs in personal injury lawsuits.
See Medicare Secondary Payer Act (MSPA) 42 U.S.C. 1395y(b)(8)(A)(i); Seger v. Tank
1
CMS has developed a "query process" under which a responsible reporting entity (RRE) (such as the City in this
case) can determine a claimant's Medicare status electronically, as long as the RRE has access to the claimant's
name, date of birth, gender and social security number. Seger v. Tank Connection, LLC, 2010 U.S. Dist. LEXIS
49013 at *13 (D. Neb. Apr. 22, 2010).
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Connection, LLC, 2010 U.S. Dist. LEXIS 49013 (D. Neb. Apr. 22, 2010) ) (“the Extension Act
adds new mandatory reporting obligations to the Medicare Secondary Payer Act ("MSPA")
requiring . . . self-insurers to provide detailed information regarding all liability settlements or
open claims with ongoing responsibility for medical treatment with Medicare beneficiaries to the
Centers for Medicare and Medicaid Services ("CMS")”). Torres v Visto Realty Corp., 2015 N.Y.
App. Div. LEXIS 3216, 1-2 (1st Dep't 2015) (“plaintiff did not satisfy his obligations under
CPLR 5003-a, since he failed to provide defendant with the information relating to his Medicare
status that defendant requires to comply with its reporting obligations under 42 USC § 1395y”)
(citations omitted); Bey v. City of New York, 2013 U.S. Dist. LEXIS 15597, at *5-6 (E.D.N.Y.
Feb. 5, 2013) (same.). Thus, the City needs to ascertain plaintiff’s Medicare status for the
purposes of satisfying its reporting obligations.
Additionally, the City also requires the personal identifying information to resolve any
outstanding Medicare claims before issuing payment on settlements. See MSPA, 42 U.S.C.
1395y(b)(2)(B)(ii) (“a primary plan’s responsibility for such payment may be demonstrated by a
judgment [or settlement] . . . for items or services included in a claim against the primary plan . .
. .”); see also Torres v. Hirsch Park, LLC, 91 AD.3d 942 (2nd Dep’t 2012) (“the authorizations
that the Supreme Court directed the plaintiff to provide are necessary for the defendant to
comply with itsstatutory duty to report the identity of a claimant who is entitled to Medicare
benefits (see 42 USC 1395y[b][8]) and to determine the existence of potential subrogation claims
[under federal law]”) (citations omitted); Liss v. Brigham Park Coop Apts., 264 A.D.2d 717 (2d
Dep’t 1999) (because the Federal government has a right of action directly against the defendant
for recovery of its lien, it was “incumbent upon plaintiff to resolve the lien and give the
defendant a release.”)
Indeed, the responsibility of assuring reimbursement of Medicare claims extends to all
entities involved in the underlying liability action, including the plaintiff’s counsel. CFR §
411.24(g); United States v. Harris, 2009 U.S. Dist. LEXIS 23956 (N.D. W. Va. Mar. 26, 2009)
(holding that plaintiff’s attorney is liable to Medicare for unpaid liens because he disbursed
settlement funds in a liability case to his client without first reimbursing Medicare for its claims).
Thus, it is to all parties’ benefit to ascertain a plaintiff’s Medicare status as early as possible so as
to resolve any existing Medicare claims and facilitate payment of settlements.
In view of the foregoing, we ask that you promptly submit to us the requested
information. If you know for a fact that your client presently receives Medicare, you should
immediately (1) notify Medicare of the pending lawsuit;2 (2) provide the Law Department with
plaintiff’s Medicare identification number and/or social security number; (3) obtain conditional
and final payment information from Medicare and (4) provide copies of any correspondences to
2
If you have never notified Medicare about this injury claim before, the first step is to report the injury to the
Benefits Coordination & Recovery Contractor (BCRC) at P.O. Box 138897, Oklahoma City, OK 73113-8897, or by
telephone at 1-855-798-2627. A case identifier will be established, and you will then receive a correspondence
from the BCRC concerning any conditional payments made by Medicare on your client’sbehalf for the injuries
underlying this case. BCRC is the agency that will issue final demand letters on amounts due Medicare. More
detailed information concerning the foregoing procedures can be found at http://go.cms.gov/cobro by clicking on
the links to the left of the screen entitled 'Non-Group Health Plan Recovery' and 'Reimbursing Medicare'. There is
also a portal on this website, the Medicare Secondary Payer Recovery Portal (MSPRP) that allows registered users
to access and update certain case-specific information online, including an electronic conditional payment letter.
Please visit the website for information as how to register for this service.
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the City. If future medical care for plaintiff is anticipated, you may also need to consider a
3
Medicare set-aside instrument for payment of future medical costs;
If plaintiff was insured under a Medicare Advantage Plan (“MAP”) under Part C of the
Medicare Act at any time after the incident at issue here, plaintiff should notify the City about
the MAP coverage, and also inform the MAP(s) of this lawsuit. Recent New York decisions
have held that a MAP provider can pursue recovery of its reimbursement and/or subrogation
claims in the same manner as traditional Medicare. See Potts v. Rawlings Co., LLC, 897 F.
Supp. 2d 185 (S.D.N.Y. 2012); Trezza v Trezza, 104 A.D.3d 37, 48 (2d Dep't 2012)
(“Based on the express preemption provision set forth in 42 USC § 1395w-26(b)(3), as well as
the regulations set forth in 42 CFR 422.108(f), we hold that General Obligations Law § 5-335,
insofar as applied to Medicare Advantage organizations under Part C, is preempted by federal
law since it would impermissibly constrain contractual reimbursement rights authorized under
the "Organization as secondary payer" provisions of the Medicare Act.”). Moreover, several
federal courts have ruled that a MAP provider can also bring a federal action to collect on its
liens under 42 U.S.C. § 1395y(b)(3)(A) - and can seek double damages thereunder. See In re
Avandia Mktg., 685 F.3d 353, 360 (3d Cir. Pa. 2012); Collins v. Wellcare Healthcare Plans, Inc.,
2014 U.S. Dist. LEXIS 174420 (E.D. La. Dec. 16, 2014). The City, therefore, will require
resolution of any Medicare-related claims as a condition to any settlement in this matter,
regardless whether the claims are asserted by the government under a traditional Medicare plan
or by a MAP under a Medicare Part C.
Thank you for your attention to the foregoing. Should you have any questions, feel free
to contact the City’s Medicare Compliance Unit at 212-356-2687.
PLEASE BE ADVISED THAT WE CANNOT FINALIZE ANY SETTLEMENT
WITH A CURRENT MEDICARE RECIPIENT WITHOUT FIRST RESOLVING
MEDICARE’S CLAIM.
Very truly yours,
Medicare Compliance Officer
Encl.
3
You should be aware that if CMS determines that Medicare's future interests were not adequately protected, CMS
may require that plaintiff expend up to the entire amount of the settlement on Medicare-covered expenses related to
the injury claimed in this lawsuit before Medicare will provide coverage for the further treatment of such injury. See
Cribb v. Sulzer Metco (US) Inc., 2012 U.S. Dist. LEXIS 134900 (E.D.N.C. Sept. 5, 2012); Sipler v. Trans Am
Trucking, Inc., 881 F. Supp. 2d 635, 638 (D.N.J. 2012). Accordingly, we suggest that plaintiff evaluate her future
medical needs with her physicians and consider creating a Medicare set-aside instrument at the appropriate time.
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The City of New York
JAMES E. JOHNSON LAW DEPARTMENT
Corporation Counsel 100 CHURCH STREET
NEW YORK, NEW YORK 10007
June 29, 2020
ROBERT DEMBIA, P.C
160 BROADWAY, ROOM 610
NEW YORK, NY 10038
Re: ERNEST WATSON AND ABBY WATSON
County: New York Ct. Index No.: 162516/2019
Our File No.: 2020-002205
Dear Counselors:
This office is unable to evaluate and review your client’s claims against THE CITY OF NEW
YORK, DET. KEVIN BRADY S/H/A DET "JOHN" BRADY, SHIELD NO.. 646 , P.O. RENE SOTO,
("CITY") without duly executed authorizations permitting the CITY to review records pertaining to your
client’s arrest, incarceration, and or criminal proceedings. A review of the file in the above named action
reveals that you have yet to provide said authorizations. In order to facilitate the discovery process,
please provide this office with the following:
Duly executed authorization permitting the Office of the Corporation Counsel to examine
and copy the records, transcripts and certificates of disposition of any criminal
proceedings concerning the claims alleged in the complaint;
Duly executed authorization permitting the Office of the Corporation Counsel to examine
and copy all records, created by, or in the possession of, the New York City Police
Department, relating to the claims alleged in the complaint; and
Duly executed authorization permitting the Office of the Corporation Counsel to examine
and copy all records, created by, or in the possession of, the District Attorney’s Office,
relating to the claims alleged in the complaint.
Enclosed is a blank authorization for your convenience. Please copy and have your client
complete a separate original authorization for the New York City Police Department, District Attorney’s
Office, and the unsealing of related criminal court records and return them to the New York City Law
Department, 100 Church Street, New York, NY 10007 at your earliest convenience. NOTE: - For cases
with more than one plaintiff please copy the blank authorization supplied herewith and return a separate
set of completed authorizations for each plaintiff alleging other than only loss of consortium claims.
Thank you for your anticipated cooperation.
Very truly yours,
JAMES E. JOHNSON
Corporation Counsel
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CONSENT AND AUTHORIZATION FOR RELEASE OF RECORDS SEALED BY
LAW, INCLUDING RECORDS SEALED PURSUANT TO CRIMINAL PROCEDURE
LAW § 160.50
Whereas, I, _____________________________________, residing at
________________________________________________, date of birth: ________________, and
Social Security # _______________, NYSID # _______________, having caused a notice of claim to be
filed or commencing an action/lawsuit against THE CITY OF NEW YORK, DET. KEVIN BRADY
S/H/A DET "JOHN" BRADY, SHIELD NO.. 646 , P.O. RENE SOTO, , demanding money damages for
false arrest, false imprisonment, malicious prosecution, assault and battery, and/or other allegations, I
hereby waive my statutory rights, for purposes of this claim/action/lawsuit, to keep sealed the records of
my arrest on or about April 1, 2019 and prosecution, including all records maintained by law enforcement
agencies, criminal courts, and/or district attorney’s office. If my case proceeded in the criminal courts,
the docket # was _______________.
Whereas, it is necessary for the above named defendant(s) to have access to the aforementioned records
of my arrest and any related criminal proceedings and incarceration in order to evaluate and review my
claims, and prepare its defense thereto, I hereby authorize any and all governmental agencies, bodies and
employees having custody of such records to release such records to the Office of the Comptroller or the
Office of the Corporation Counsel of the City of New York, or its authorized agent or employee. I
specifically authorize the New York City Police Department; New York County District Attorney’s
Office; New York State Supreme Court, New York County, Criminal Term; and New York City Criminal
Court to disclose any and all records in their possession relating to the aforementioned arrest/prosecution
and docket number to the Office of the Corporation Counsel of the City of New York, or its authorized
agent or employee.
____________________________________
Plaintiff/Claimant
Sworn to before me this ______ day of ____________, 20___
______________________________
NOTARY PUBLIC
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SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
------------------------------------------------------------------------x
ERNEST WATSON AND ABBY WATSON,
AMENDED ANSWER
Plaintiff(s),
-against- Index #: 162516/2019
THE CITY OF NEW YORK; DET. "JOHN" BRADY, Law Dept. #: 2020-002205
SHIELD NO. 646 AND P.O. RENE SOTO,
Defendant(s).
------------------------------------------------------------------------x
Defendants THE CITY OF NEW YORK, DET. KEVIN BRADY S/H/A DET
"JOHN" BRADY, SHIELD NO. 646, P.O. RENE SOTO, by upon JAMES E. JOHNSON,
Corporation Counsel, answering the complaint, allege information and belief:
1. Deny each allegation set forth in paragraph(s) 2, 8-11, 15, 17, 18, 20, 21,
23, 24, 26-32, 34, 35, 37-39, 41-43, 47-51, 52(1st), 53, 54, inclusive.
2. Deny knowledge or information sufficient to form a belief with respect to
the truth of the allegations set forth in paragraph(s) 1, 3, 4, 6, 12, 44, 45, 46, 52(2nd), inclusive.
3. Deny the allegations set forth in paragraph(s) 13, 14, inclusive, except
that a notice of a claim was presented, that more than thirty days have elapsed without
adjustment thereof.
4. Deny each allegation set forth in paragraph(s) 5-7, inclusive, except that
the City of New York is a municipal corporation that employed Det. Kevin Brady and Rene Soto
who acted within the scope of their employment.
5. Deny each allegation set forth in paragraph(s) 16, 19, 22, 25, 33, 36, ,
inclusive, except as otherwise pleaded herein.
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AFFIRMATIVE DEFENSE(S)
6. Plaintiff(s)’ culpable conduct caused or contributed, in whole or in part, to
his/her/their injuries and or damages.
7. At all times mentioned in the complaint, plaintiff(s) knew or should have
known in the exercise of due/reasonable care of the risks and dangers incident to engaging in the
activity alleged. Plaintiff(s) voluntarily performed and engaged in the alleged activity and
assumed the risk of the injuries and/or damages claimed. Plaintiff(s) failed to use all required,
proper, appropriate and reasonable safety devices and/or equipment and failed to take all proper,
appropriate and reasonable steps to assure his/her/their safety. Plaintiff(s)’ primary assumption
of risk solely caused his/her/their injuries and/or damage and defendant(s) owed no duty to the
plaintiff(s) with respect to the risk assumed. Plaintiff(s)’ express assumption of risk solely
caused his/her/their injuries and/or damage and defendant(s) owed no duty to the plaintiff(s) with
respect to the risk assumed. Plaintiff(s)’ implied assumption of risk caused or contributed, in
whole or in part to his/her/their injuries. In any action for injuries arising from the use of a
vehicle in, or upon which plaintiff(s) were riding; it will be claimed that the injuries and/or
damages sustained were caused by the failure of the plaintiff(s) to use available seat-belts and/or
other safety devices.
8. Defendants are immune from suit for their exercise of discretion in the
performance of a governmental function and/or their exercise of professional judgment.
9. The amounts recoverable by plaintiff(s) are subject to limitation pursuant
to Section 1601 of the Civil Practice Law and Rules, by reason of the culpable conduct of other
person(s) who are, or with reasonable diligence could have been made party defendant(s) to this
action, or pursuant to Section 15-108 of the General Obligations Law, by reason of a prior
settlement between plaintiff(s) and said person(s), or pursuant to Section 4545 of the Civil
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Practice Law and Rules are subject to reduction by collateral sources received by plaintiff(s), or
by reason of the fact that punitive damages are not recoverable against municipal defendant(s).
10. If plaintiff demonstrates that the acts complained of were undertaken in
the scope of the actor(s) employment, then such acts as may have been committed by law
enforcement officers in the employ of the City of New York were justified as being reasonably
necessary, and were committed in good faith without malice and with probable cause, and in the
exercise of professional judgment or the performance of discretionary functions for which
defendant(s) are qualifiedly privileged under the laws of this State and of the United States.
Individual defendant(s) represented by the Office of the Corporation Counsel (if any) did not
violate any clearly established constitutional or statutory right of which a reasonable person
would have known and therefore are/is protected by qualified immunity.
11. Such statements as were made concerning the plaintiff(s) were privileged
as being true, or fair comment upon matters of opinion, and were made in the good faith belief in
their truth without malice to person(s) having a like duty or interest therein.
12. This court lacks jurisdiction over the defendant(s) THE CITY OF NEW
YORK, in that said defendant(s) were not personally served with the summons.
13. Plaintiff(s)’ complaint fails to consecutively number allegations as
required by section 3014 of the CPLR.
14. Plaintiff(s)’ complaint fails to state a cause of action upon which relief can
be granted.
15. Plaintiff(s)' complaint fails to comply with section 3017(c) of the CPLR.
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WHEREFORE, defendant(s) demand judgment dismissing the complaint and all
cross-claims against them, or, in the event that they are adjudged liable, granting judgment over,
or apportioning such liability in accordance with their equitable shares of responsibility, and
awarding the costs of this action, together with such other and further relief as to the court may
seem just.
JAMES E. JOHNSON
Corporation Counsel
100 Church Street
New York, New York 10007
* Served while working remotely during the COVID-19 emergency.
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Index #: 162516/2019
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
ERNEST WATSON AND ABBY WATSON,
Plaintiff(s),
- against -
THE CITY OF NEW YORK; DET. "JOHN" BRADY, SHIELD NO. 646 AND
P.O. RENE SOTO,
Defendant(s).
COMBINED DEMAND FOR
BILL OF PARTICULARS & DISCOVERY
JAMES E. JOHNSON
Corporation Counsel
Attorney for Defendants THE CITY OF NEW YORK, DET. KEVIN BRADY
S/H/A DET "JOHN" BRADY, SHIELD NO.. 646 , P.O. RENE SOTO, 100
Church Street
New York, New York 10007
Telephone Numbers:
Early Intervention Unit (settlements – all Boroughs)
(212) 356-1665
Pleadings Unit (212) 356-3235 (pleadings matters only)
All Other Matters (Inquire by county of venue)
Bronx Office: (718) 503-5030 (EBT’s - 5045)
Brooklyn Office: (718) 724-5200 (EBT's-5226)
Manhattan Office: (212) 356-2725 (EBT's-2791)
Queens Office: (718) 558-2100 (EBT's - 2105)
Staten Island Office: (718) 876-3600 (EBT's-3603)
Please refer to the following Law Dept. #: 2020-002205
and indicate the County in which the action is pending in all papers,
correspondence and other communications with respect thereto.
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SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
------------------------------------------------------------------------x
ERNEST WATSON AND ABBY WATSON,
COMBINED DEMAND FOR
Plaintiff(s), VERIFIED BILL OF
PARTICULARS & DISCOVERY
-against-
THE CITY OF NEW YORK; DET. "JOHN" BRADY, SHIELD
NO. 646 AND P.O. RENE SOTO,
Defendant(s).
------------------------------------------------------------------------x
DEMAND FOR VERIFIED BILL OF PARTICULARS
PLEASE TAKE NOTICE that pursuant to CPLR 3041, plaintiff(s) is required within 30
days following service of this demand to serve upon JAMES E. JOHNSON, Corporation Counsel, a verified
bill of particulars setting forth in reasonable detail a statement of the following:
1. The exact date and time of the act or occurrence.
2. The specific location of the act or occurrence with reference to addresses, landmarks, or
other identifying points of reference, including the direction and distance therefrom. If the occurrence took
place inside a premise, state specifically the location within the premise and also include the block and lot of
the premises.
3. State the injuries claimed, if any.
4. State those injuries claimed to be permanent.
5. If applicable, set forth the length of time it is alleged the plaintiff(s) was confined to:
(a) Hospital(s);
(b) Bed;
(c) House.
6. If applicable, set forth the amount claimed as special damages for:
(a) Physician(s) services;
(b) Nurses services;
(c) Hospital expenses;
(d) Drugs and medical supplies;
(e) X-rays and diagnostic tests.
For each of the foregoing elements of damages please state the name and address(es) of the
provider(s) and the dates of treatment. If any of the foregoing elements of damages have been repaid to the
plaintiff(s) or otherwise paid for by other sources, identify each type of service recompensed, the source or
sources of such recompense, the amount so paid and the net amount of out of pocket expenses sustained by
the plaintiff(s).
7. If applicable, state the total amount of all other special damages not specified in items
above; and please state the
(a) name and address of each service provider;
(b) each date of the service;
(c) amount of the expense for each provider;
(d) amount of any expense paid by a third-party (including any payment made to
reimburse plaintiff);
(e) name and address of the third-party paying any expense; and
(f) amount of any unreimbursed expense paid by plaintiff(s) personally to each
provider.
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8. State the occupation of plaintiff(s) at the time of the incident; and please state the:
(a) name and address of any employer for 5 years prior to alleged incident and up to
the time of trial;
(b) length of time totally disabled from work;
(c) length of time partially disabled from work;
(d) amount claimed for lost earnings, if any;
i. if a loss of earnings claim is alleged, please state the yearly gross earnings for
each year during 5 years prior to alleged incident and up to the time of trial;
and
(e) number of days absent from work as a result of injuries sustained from the
incident.
9. State the (a) name and address of any school attended by plaintiff(s) for 5 years prior to
alleged incident and up to the time of trial; and (b) the number of days lost from school as a result of injuries
sustained from incident.
10. State the home address of plaintiff(s) for a period of 5 years prior to the alleged incident
to the present.
11. State any other name used by plaintiff(s) and the time period when the name was used.
12. State the date of birth and social security number of plaintiff(s) (disclosure of social
security number is voluntary). If a social security number is disclosed, it will be used by defendant(s) to
determine whether plaintiff(s) is (are) Medicaid recipient(s) for purposes of determining whether a Medicaid
lien may attach to any judgment or settlement obtained against the defendant(s).
13. State whether plaintiff(s) is (are) Medicare recipient(s). If plaintiff is or was a Medicare
recipient please provide their Medicare identification number and social security number (disclosure of
social security number is voluntary). If a social security number is disclosed, it will be used by
defendant(s) to verify that plaintiff(s) is (are) Medicare recipient(s) for purposes of defendant(s) meeting its
(their) Medicare reporting obligations.
14. If plaintiff(s) has ever been convicted of a crime (including any guilty plea), please state
(a) the NYSID number of plaintiff; (b) the dates of every conviction; (c) whether the conviction was state or
federal; and (d) the county where each conviction occurred.
15. If the complaint alleges loss of services, set forth the pecuniary loss, if any, alleged in
the complaint. Enumerate the damages for:
(a) Loss of services;
(b) Consortium;
(c) Other expenses.
16. State those injuries arising from the use or operation of a motor vehicle which are
claimed to be serious, as defined in Insurance Law § 5102 (d), if any.
17. If property damage is claimed, please state (a) all property damaged; (b) the fair market
value of each item at the time it was damaged; (c) the cost of repairing each item; (d) the cost of replacing
each item; (e) the date each item was acquired; (f) the purchase cost of each item; (g) the amount(s) provided
by a third-party to reimburse damage; (h) the name and address of any third-party which reimbursed damage;
and (i) amount of any unreimbursed payment made by plaintiff(s) to replace or repair a damaged item.
18. State the manner in which it is claimed the accident occurred.