G
`GOLDiif H MIl L 6 HLI@tIN
`From: Harlan Schreiber
`Subject:
`FW: Victor Chalen
`To:
`NYNF EUO; Emanuel Sadykov
`Sent:
`January 8, 2024 12:31 PM (UTC-05:00)
`Attached:
`NO FAULT REP LETTER (3).pdf
`Thx will do
`
`HARLAN R. SCHREIBER, PARTNER
`1501 BROADWAY, SUITE 715
`NEW YORK, NEW YORK 10036
`hschreiber@gmrlawfirm.com
` |
`gmrlawfirm.com
`P: 646.863.1531 | F: 929.214.4181
`Direct Dial: 646.503.5791
`
`From:
` Emanuel Sadykov <emanuel@raytsinlaw.com>
`Sent:
` Monday, January 8, 2024 11:15 AM
`To:
` Harlan Schreiber <hschreiber@gmrlawfirm.com>
`Subject:
` Re: Victor Chalen
`
`CAUTION:
` This email originated from outside of the organization. Do not click links or open attachments
`unless you recognize the sender and have verified that the content is safe.
`Hi, please see attached LOR. Please let us know when the next date is and send the new notice to my email. Thank
`you.
`
`On Fri, Jan 5, 2024 at 1:46 PM Harlan Schreiber <
`hschreiber@gmrlawfirm.com
`> wrote:
`We have no LOR from your office. Please send an LOR and we’ll copy you on the second opportunity letter…
`
`HARLAN R. SCHREIBER, PARTNER
`1501 BROADWAY, SUITE 715
`NEW YORK, NEW YORK 10036
`hschreiber@gmrlawfirm.com
` |
`gmrlawfirm.com
`P: 646.863.1531 | F: 929.214.4181
`Direct Dial: 646.503.5791
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`
`G
`GOLDilf HLi MIL l L HllHIN
`
`From:
` Emanuel Sadykov <
`emanuel@raytsinlaw.com
`>
`Sent:
` Friday, January 5, 2024 1:42 PM
`To:
` Harlan Schreiber <
`hschreiber@gmrlawfirm.com
`>
`Subject:
` Victor Chalen
`
`CAUTION:
` This email originated from outside of the organization. Do not click links or open
`attachments unless you recognize the sender and have verified that the content is safe.
`Hi, my client had an EUO scheduled for today, 1/5 @ 10 AM but we never received the notice until today sent by
`the medical office. We had no recollection of this EUO, did you send it to us? Can you please reschedule it?
`Please let me know at your earliest convenience, thank you !
`
`--
`Best Regards,
`Emanuel Sadykov
`Raytsin Law Firm, P.C.
`P: 718-355-9797 | 888-RAYTSIN
`F: 718-223-5953
`www.raytsinlaw.com
`
`The contents of this electronic transmission are being sent by The Raytsin Law Firm, P.C. at 221-10 Jamaica Avenue, Suite
`106, Queens Village, NY 11428 and are ATTORNEY PRIVILEGED AND CONFIDENTIAL. If you have received this electronic
`transmission in error or if you are unsure whether it is privileged, please notify me immediately by telephone at (718)355-9797 and
`return the original document in its entirety to us at the above address via the U.S. Postal service. ANY DISSEMINATION,
`DISTRIBUTION, COPYING, OR TAKING ANY ACTION IN RELIANCE ON THE CONTENTS OF THIS COMMUNICATION BY
`ANYONE OTHER THAN THE INTENDED RECIPIENT IS STRICTLY FORBIDDEN.
`THE INFORMATION CONTAINED IN THIS EMAIL COMMUNICATION IS INTENDED ONLY FOR THE
`PERSONAL AND CONFIDENTIAL USE OF THE DESIGNATED RECIPIENT NAMED ABOVE. This
`message may be an Attorney-Client communication and/or Attorney Work Product, and as such is privileged and
`confidential. If the reader of this message is not the intended recipient, you are hereby notified that you have
`received this communication in error and that any review, dissemination, distribution, or copying of the message
`is strictly prohibited. If you have received this transmission in error, please destroy this transmission and notify
`us immediately by telephone and/or reply email.
`
`--
`Best Regards,
`Emanuel Sadykov
`Raytsin Law Firm, P.C.
`P: 718-355-9797 | 888-RAYTSIN
`F: 718-223-5953
`www.raytsinlaw.com
`
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
`
`
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`
`
`The contents of this electronic transmission are being sent by The Raytsin Law Firm, P.C. at 221-10 Jamaica Avenue, Suite
`106, Queens Village, NY 11428 and are ATTORNEY PRIVILEGED AND CONFIDENTIAL. If you have received this electronic
`transmission in error or if you are unsure whether it is privileged, please notify me immediately by telephone at (718)355-9797 and
`return the original document in its entirety to us at the above address via the U.S. Postal service. ANY DISSEMINATION,
`DISTRIBUTION, COPYING, OR TAKING ANY ACTION IN RELIANCE ON THE CONTENTS OF THIS COMMUNICATION BY
`ANYONE OTHER THAN THE INTENDED RECIPIENT IS STRICTLY FORBIDDEN.
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
`
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`
`RAYTSIN
`Raytsin Law Firm, P.C.
`221-10 Jamaica Avenue; Suite 106
`Queens Village, NY 11428
`Tel: 718-355-9797 | 888-RAYTSIN
`Fax: 718-223-5953
`
`
`
`
`10/31/2023
`Dear Sir/Madam:
`
`Insurance Co. KEMPER INSURANCE
`
`
`Attention No-Fault Claims & Uninsured/Underinsured Department:
`
` RE:
` Claimant(s): VICTOR HERNANDEZ & GARCIA XIOMARA
`
`DOA: 10/30/2023
`Claim #: 23123895252
` Insured: VICTOR HERNANDEZ
`
`
`
`Please be advised that my firm represents the above-referenced injured claimant (s) with
`respect to serious injuries sustained in a motor vehicle accident as above referenced.
`
` Enclosed please find the executed no-fault applica tion and police report for the
`claimant(s). Please kindly forward all future correspondence regarding the above referenced
`matter to my office.
`
` Also, at this time, my client(s) would like to mak e an uninsured/underinsured motorist
`claim against the above referenced policy with respect to said accident. Please forward a copy of
`this request to your uninsured/underinsured department.
`
`
` Very truly yours,
`
` Boris Raytsin, Esq.
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`NEWYORKMOTORVEHICLENO-FAULTINSURANCELAW
`APPLICATIONFORMOTORVEHICLENO-FAULTBENEFITS
`NAMEANDADDRESSOFINSURER* NAME,ADDRESS,ANDPHONENUMBEROFINSURER'S
`CLAIMSREPRESENTATIVE*
`E QCY OLDE POLfCYNUMBER DATE, F ACC ENT CI.AIM NUMBER
`TOENABLEUSTODETERMINEIF YOURAREENTITLEDTOBENEFITSUNDERTHENEWYORKNO-FAULTLAW,PLEASECOMPLETETHIS FORMANDRETURNITPROMPTLY.
`IMPORTANT:1. TOBEELIGlBLE FORBENEF1TSYOUMUSTCOMPLETEANDSIGNTHISAPPLICATION.
`2. YOUMUSTSIGNANYATTACHEDAUTHORIZATION(S).
`3 RETURNPROMPTLYWITHCOPIESOFANYBILLS YOUHAVERECEIVEDTODATE
`\
`NAMEANDADDRESSOFAPPLICANT*
`p RNAME 2. PiloNE NOS. E BUSINT
`3. YO RADDRESS 4. ' TEOr UIRYii |S. SOCIAI SECURITYNO.
`NO., STREET,CITYORTOW4NDZIP CODE)
`6 DATlI ANDTIMEO

ÅCCIDENT 7 PLACEOFACCIDENT(STREET), CITYORTOWNANDSTATE
`A.M.
`P.M.
`8. HRIEFDESCRIPTIONOFACCIDENT
`9. DESCRIBEYOURINJURY
`t10. IDENTITYOFVEHICLEYOUOCCUPlED OPERATED THE E OF IEACCIDENT:
`OWNEl3h&ME .M._815E ..y.E
`THISVEHICLEWAS: A BUSORSCHOOLBUS, | TRIJCK. NAUTOMOBILE,ORA MOTORCYCLE
`NO
`11. WEREYOUTHEDRIVEROFTHEMOTORVEH1CLE?
`WEREYOUA PASSENGERIN THEMOTORVEHICLE?
`WEREYOUA PEDESTRIAN?
`WEREYOUA MEMBEROFOURPOLICYHOLDER'sHOUSEHOLD?
`DOYOUORA RELATIVEWITHWHOMYOURESIDEOWNAMOTORVEHICLE?
`CONTINUATIONONNEXTPAGE
`NYSFORMNF-2 (Rev 1/2004)
`Page 1 of 3
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`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`APPUCATIONFORMOTORVEHICLENO-FAULTBENEFITS- - PAGETWO
`12. WEREYOUTREATEDBYA OCTOR(S)OROTHERPERSON(S)FURNISHINGHEALTHSERVICES?
`YES NO
`IF YES, NAMEANDADD SSO SUCHDOCTO PERSON :
`13. IF YOURWERETREATEDATA l.S TAI.(5), WERii UAN
`OUT-PATIENT? IN.P IE
`DATEOFADMISSION:
`HOSPITAL'SNAMEANDADDRESS:
`14. AMOUNTOFHEA1TH 16. WILLYOUHAVEMOREHEALTH 16. AT THEŠlME OFYOUlt ACCIDENTWERF
`BILLS TODATE: TREATMENT(S)? YOUIN THECOURSEOFYOUR
`NO EMPLOYMENT?
`3 YES N
`I I I
`17. DIDYOULOSETIME DATEABSENCEFROM HAVEYOURETURNEOTOFROMWORK? WORKBEGAN WORK?
`YES NO YES NO
`F YES, DATERETURNEDTOWORK: AMOUNT)F TIMELOSTFROMWORK:
`18. WHATAREYOURGROSSAVIiRAGE NUMBEROFDAYSYOUWORK NUMBEROFHOURSYOUWDRKWEEKLYEARNINGS? PERWEEK: PERDAY:
`19. WEREYO.URECEiVINGUNEMPLOYM- JT GENEFIT$At 1HE1IML Of' THEA
`CIDENT1
`YES NO
`20 LIST NAMESANDADDRESSOFYOUREMPI.OYERANOOTIIER EMPt.OYERSFORONEYEARPRIORTOACCIDENTDATEANDGIVE OCCUPATIONANDDATESOFEMPLOYMENT:
`EMPLOYERANDADDRESS OCCUPATION FROM TO
`EMPLOYERANDADDRESS OCCUPATION FROM TO
`EMPLOYERANDADDRESS OCCUPATION FROM TO
`2.1 ASA 8ES.ULTOFYOURthUURYHAV8YOUHADANY HEREXPENSES1
`YES NO /)|
`IF YES,ATTACHEXPLANATIONANDAMOUNTSOFS CHEXPENSES.
`22 DUETOTHIS ACCIDENTHAVEYOURECElVEDORAREYOUFLIGli31.F FORPAYMENTSUNDERANYOFTHEFOLLOWING:
`YES
`NEWYORKSTATEDISABILITY?
`WORKERS'COMPENSATION?
`CONTINUATIONONNEXTPAGE
`NYSFORMNF-2 (Rev 1/2004)
`Page2 of 3
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
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`APPLICATIONFORMOTORVEHICLENO-FAULTBENEFITS- - PAGETHREE
`THEAPPLICANTAUTHORIZESTHEINSURERTOSUBMITANYANDALL OFTHESEFORMSTOANOTHERPARTYORINSURERIF SUCHIS NECESSARYTOPERFECTITS RIGHTSOFRECOVERYPROVIDEDFORUNDERTHE
`NO-FAULTLAW.
`THIS FORMIS SUBSCRIBEDANDAFFIRMEDBYTHE
`APPLICANTASTRUEUNDERTHEPENALTIESOFPERJURY
`ANYPERSONWHOKNOWINGLYANDWITHINTENTTODEFRAUDANYINSURANCECOMPANYOROTHERPERSONFILES ANAPPLICATIONFORCOMMERCIALINSURANCEORA STATEMENTOF CLAIMFORANYCOMMERCIALORPERSONALINSURANCEBENEFITSCONTAININGANYMATERIALLYFALSEINFORMATION,ORCONCEALSFOR THE PURPOSEOFMISLEADING,INFORMATIONCONCERNINGANYFACTMATERIAL
`THERETO,ANDANYPERSONWHO,IN CONNECTIONWITHSUCHAPPLICATIONORCLAIM, KNOWINGLYMAKESORKNOWINGLYASSISTS, ABETS,SOLICITSORCONSPIRESWITHANOTHERTOMAKEA FALSE
`REPORTOFTHETHEFT,DESTRUCTION,DAMAGEORCONVERSIONOF ANYMOTORVEHICLETOA LAWENFORCEMENTAGENCY, THE DEPARTMENTOF MOTORVEHICLES ORAN INSURANCECOMPANY,COMMITSAFRAUDULENTINSURANCEACT, WHICHIS ACRIME,ANDSHALLALSOBESUBJECTTOA CIVIL
`PENALTYNOTTOEXCEEDFIVE THOUSANDDOLLARSANDTHEVALUEOFTHESUBJECTMOTORVEHICLEORSTATEDCLAIMFOREACHVIOLATION.
`AUTHORIZATIONFORRELEASEOFWORKANDOTHERLOSSINFORMATION
`THIS AUTHORIZATIONORPHOTOCOPYTHEREOF,WILL AUTHORIZEYOUTOFURNISHALL INFORMATIONYOUMAYHAVEREGARDINGMYWAGES,SALARYOROTHERLOSSWHILEEMPLOYEDBYYOU. YOURAREAUTHORIZEDTOPROVIDETHIS INFORMATIONIN ACCORDANCEWITH THE NEWYORK COMPREHENSlVEMOTORVEHICI EINSURANCE A TONSACT(NO- LT LAW).
`NAME T ORTYPE 500 L ECURI Y NO.
`SIG TUA. E
`..- .. .. ... .. .. .. .. .. . . . ..,. ., .. . .. . . ...... .... .. . ., . ....... , .... . .... ....,.., -
`AUTHORIZATIONFORRELEASEOFHEALTHSERVICEORTREATMENTINFORMATION
`THIS AUTHORIZATIONORPHOTOCOPYTHEREOF,WILL AUTHORIZEYOUTOFURNISHALL INFORMATIONYOUMAYHAVEREGARDINGMYCONDITIONWHILEUNDERYOUROBSERVATIONORTREATMENT,INCLUDINGTHEHISTORY
`OBTAINED, X-RAYSANDPHYSICALFINDINGS, DIAGNOSISANDPROGNOSIS.YOUAREAUTHORIZEDTO PROVIDETHIS INFORMATIONIN ACCO CE WITHTHE NEWYORKCOMPREHENSIVEMOTORVEHICLE INSURANCEREPA T ONSA T (NO- ULT
`NAME(PRINTOR PE)
`SIGNA1 JRE OATE
`(IF THEAPPLICANTIS A MINOR,PARENTORGUARDIANSHALLSIGNANDINDICATECAPACITYANDRELATIONSHIP)
`*LANGUAGETOBEFILLED IN BYINSURERORSELF-INSURER
`NYSFORMNF-2 (Rev 1/2004)
`Page 3 of 3
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`NEWYORKMOTORVEHICLENO-FAULTINSURANCELAW
`APPLICATIONFORMOTORVEHICLENO-FAULTBENEFITS
`NAMEANDADDRESSOFINSURER. NAME.ADDRESS,ANDPHONENUMBEROFINSURER'S
`CLAIMSREPRESENTATIVE"
`D TE PO ICY OL POLICYNUMBER DAT OF CCI N CI.AIM NUMBER
`TOENABLEUSTODETERMINEIF YOURAREENTITLEDTOBENEFITSUNDERTHENEWYORKNO-FAULTLAW,PLEASECOMPLETETHIS FORMANDRETURNITPROMPTLY.
`IMPORTAN1: 1. TOBE ELIGlBLE FORBENEFITSYOUMUSTCOMPLETEANDSIGNTHISAPPLICATION.
`2. YOUMUSTSIGNANYATTACHEDAUTHORIZATION(S).
`3 RETURNPROMPTLYWITHCOPIESOFANYBILLS YOUHAVERECEIVEDTODATE
`NAMEANDADDRESSOFAPPLICANT*
`1 YO RNAME 2. PIONENOs. Ho SU*INESS
`/3. Ult ADDRESS 4. Or UIRTIl |S. SOCIAI. SITCURI YNo.
`NO., STREET,CITYORTOWNANDZIP COD
`6 DATit ANDI'IME OFACCIDENT 7 Pt ACEOFACCIDENT(STREET), CITY ORTOWNANDSTATE
`A.M.
`P.M.
`8. HRIEFDESCRIPTIONOFACCIDENY
`9, DÈSCRIBEYOURINJURY
`10. IDENTfYOFVEHICLEYOUOCCUPIEDOROPERATEDAT E TIMEOr 'f EACCIDENT:
`OWNNEBM8N.E MajSE yf
`THIS VEHICLEWAS: A BUSORSCHOOLBUS, ATRUCK. ANAUTOMOBILE,ORA MOTORCYCLE
`YE
`11. WEREYOUTHEDRIVEROFTHEMOTORVEHICLE?
`WEREYOUA PASSENGERIN THEMOTORVEHICLE7
`WEREYOUA PEDESTRIAN?
`WEREYOUA MEMBEROFOURPOLICYHOLDER'SHOUSEHOLD?
`DOYOUORA RELATIVEWITHWHOMYOURESIDEOWNAMOTORVEHICLE?
`CONTINUATIONONNEXTPAGE
`NYSFORMNF-2 (Rev 1/2004)
`Page 1 of 3
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`APPLICATIONFORMOTORVEHICLENO-FAULTBENEFITS- - PAGETWO
`12. WEREYOtJ TREATEDBYA DOCTOR(S)OROTHERPERSON(S)FURNISHINGHEALTHSERVICES7
`YES NO
`I.F YES, NAMEANDADD ESS SUCHD CTO
`13. IF YOURWERETHEATEDATAHOSP Al.(S), WERE U
`OUT-PATIENT? IN-P IE
`DATEOFADMISSION:
`HOSPITAL'SNAMEANDADDRESS:
`14. AMOUNTOFHEAt TH 16. WILLYOUF AVEMOREHEALTH 10. AT THETIMEOFYOUR·ACCIDENTWERE
`BILLS TODATE: TREATMENT(S)? YOUIN THECOURSEOFYOUR
`NO EMPLOYMENT?
`$ YES
`1 I I
`l'/. DID YOULOSETIME DATEABSENCEFROM HAVEYOURETURNEDTOFROMWORK? WORK13EGAN: WORK?
`YES NO YES NO
`IF YES. DATERETURNEDTOWORK: AMOUNT)F TIMELOSTFROMWORK:
`18. WHATAREYOURGROSSAVERAGE NUMBEROFDAYSYOUWOHK NUM8tin OFHOURSYOUWORKWEEKLYEARNINGS? PERWEEK: PERDAY:
`19. WEREYO.URECEtVll40 UNEMÞLOYMNTBENEFITSATTFIE TIMEOFTHEACC El T1
`YES NO
`20 LIST NAMESANDADDRESSOFYOUREMPI.OYERANDOTI fER EMPI.OYERSFORONEYEARPRIORTOACClDENTDATEANDGIVE OCCUPATIONANDDATESOFEMPLOYMENT:
`EMPLOYERANDADDRESS OCCUPATION FROM TO
`EMPLOYERANDADDRESS OCCUPATION FROM TO
`MPLOYERANDADDRESS OCCUPATION FROM TO
`21 A$A f¶ESULTOFY.OURINJUftY HAVEYOUHADAN O't lER EXPENSES
`YES NO / |
`IF YES,ATTACHEXPLANATIONANDAMOUNTSOFSUCHEXPENSES.
`22. DUETOTHIS ACCIDEhlTHAVEYOUHECElVEDORAREYOUFI,lGli31.F FORPAYMENTSUNDERANYOFTHEFOLLOWING:
`YES
`NEWYORKSTATEDISABILITY? |
`WORKERS'COMPENSATION7
`CONTINUATIONONNEXTPAGE
`NYSFORMNF-2 (Rev 1/2004)
`Page 2 of 3
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`APPLICATIONFORMOTORVEHICLENO-FAULTBENEFITS- - PAGETHREE
`THEAPPLICANTAUTHORIZESTHEINSURERTOSUBMITANYANDALLOFTHESEFORMSTOANOTHERPARTYORINSURERIF SUCHIS NECESSARYTOPERFECTITS RIGHTSOFRECOVERYPROVIDEDFORUNDERTHE
`NO-FAULTLAW.
`THIS FORMIS SUBSCRIBEDANDAFFIRMEDBYTHE
`APPLICANTASTRUEUNDERTHEPENALTIESOFPERJURY
`ANYPERSONWHOKNOWINGLYANDWITHINTENTTO DEFRAUDANYINSURANCECOMPANYOROTHERPERSONFILES ANAPPLICATIONFORCOMMERCIALINSURANCEORA STATEMENTOF CLAIM FORANYCOMMERCIALORPERSONALINSURANCEBENEFITSCONTAININGANYMATERIALLYFALSEINFORMATION,ORCONCEALSFORTHE PURPOSEOF MISLEADING,INFORMATIONCONCERNINGANYFACT MATERIAL
`THERETO,ANDANYPERSONWHO,IN CONNECTIONWITHSUCHAPPLICATIONORCLAIM, KNOWINGLYMAKESORKNOWINGLYASSISTS, ABETS,SOLICITS ORCONSPIRESWITHANOTHERTOMAKEA FALSE
`REPORTOFTHE THEFT,DESTRUCTION,DAMAGEORCONVERSIONOF ANYMOTORVEHICLETOA LAWENFORCEMENTAGENCY, THE DEPARTMENTOF MOTORVEHICLES OR AN INSURANCECOMPANY,COMMITSAFRAUDULENTINSURANCEACT, WHICHIS ACRIME,ANDSHALLALSOBESUBJECTTOA CIVIL
`PENALTYNOTTOEXCEEDFIVE THOUSANDDOLLARSANDTHEVALUEOFTHESUBJECTMOTORVEHICLEORSTATEDCLAIMFOREACHVlOLATION.
`IGf4ATURI: TE
`...... ...... . ..............:... .. . . . ....:....,. ,_:................ .. , . . . .. . ... ..... .. .. .. .. . . - . . . . ... .... ....., -
`AUTHORIZATIONFORRELEASEOFWORKANDOTHERLOSSINFORMATION
`THIS AUTHORIZATIONORPHOTOCOPYTHEREOF,WILL AUTHORIZEYOUTOFURNISHALL INFORMATIONYOUMAYHAVEREGARDINGMYWAGES,SALARYOROTHERLOSSWHILEEMPLOYEDBYYOU. YOURAREAUTHORIZEDTOPROVIDETHIS INFORMATIONIN ACCORDANCEWITH THE NEWY """"''** " ^'' "'-"" "
`INSURANCEREPARATIONSACT(NO-FAULTLAW).
`NAM. (P INT ORTYP so I L CURIT NO.
`slGNAti TE
`AUTHORIZATIONFORRELEASEOFHEALTHSERVICEORTREATMENTINFORMATION
`THIS AUTHORIZATIONORPHOTOCOPYTHEREOF,WILL AUTHORIZEYOUTOFURNISHALL INFORMATIONYOUMAYHAVEREGARDINGMYCONDITIONWHILEUNDERYOUROBSERVATIONORTREATMENT,INCLUDINGTHEHISTORY
`OBTAINED, X-RAYSANDPHYSICALFINDINGS, DIAGNOSIS ANDPROGNOSIS.YOUAREAUTHORIZEDTO PROVIDETHIS INFORMATIONIN ACCORDANCE THE NEWYORK COMPREHENSIVEMOTORVEHICLE INSURANCEREPARATIONSACT(NO-FAULTLAW). ,
`NA E (PRINT ORTYPE)
`SIGNA1URE
`(IF THEAPPLICANTIS A MINOR,PARENTORGUARDIANS@lALL SIGN ANDINDICATECAPACITYANDRELATIONSHIP)
`"LANGUAGETOBEFILLED IN BYINSURERORSELF-INSURER
`NYSFORMNF-2 (Rev 1/2004)
`Page 3 of 3
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`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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`MV-104 (5/22) PAGE1 of 2 FOLD Ä-- HERE
`NewYork State Department of Motor Vehicles
`( °happ°e n e or tate ) REPORTOF MOTORVEHICLEACCIDENT
`www.dmv.ny.gov
`c ENTDATE Page of RUSH- DRIVEROFVEHICLE1 - LICENSESUSPENDEDFORFAILURETOREPORT
`dent te D Week Tim Nu f Numbe umber Did police Investigate If "Yes". Nameof Police Agency or Precinct &Accident NumberO AM Vehi Injured Iled accident at scene?
`PM Yes
`DR Of VEHICLE1 EHICLE2 OPEDESTRIAN OB1CYCLIST OOTHERPEDESTRIAN
`Driver License ID Number State of License Dnver License ID Number late of License 2
`Driver Na s pri on lice . , M.I.) Namoexactly s num~5
`Address (I ml d Number & S -I Ap1.Number Addrest, (inclu r & Struct Apt. Number
`CI City or Town State Zip City or Tow Stap
`' i Codu
`So Number of Public Dale of rth Se Number of blicPeople in Property Da y People in PropertyVehicle Damaged . Vehide DamagedO 3
`Name-exactly as rin(ed on regislrdllon Date of Birth Sex Name-exactl ed egis tBn Date of Birth Sex
`Address (it uda Nun or Stre ) Apt. Number Address (h · Number & Street) Apt. Number
`City or Town State Zip Code City or Tov n State Zip Code
`Plate Number State f . Vehicle Year & Make V cle Type ins. Cc o Plat .Num r of Rer Vehide Year & Make ude Type Ins. Code
`Estimated Cost of Property Damage- Vehicle 1 Estimated Cost of Property Damage- Vehicle 2
`O$1,001-$1,500 O$1,501-$2,500 O Over $2,500 O$1,001-$1,500 1,501-$2,500 O Over $2,500 6
`LLI Describe damageto vehicle 1 ACCIDENTDIAGRAM:Cirde one of the 9 diagrams (numb :red 0-8) if it Left Turn e End Sideswipe Describe damageto vehicle 2
`O describes the accident, or draw your own diagram below in space #9, (same direction)
`Number the vehicles. Your vehicle is # 1 . + Ä--- +
`0. 2
`Left Turn RighTAngle Right Turn
`-º
`3. 4. 5 2
`Right Tum Head On Sideswipe
`(oppositedirection)
`9, 6. 7. 8.
`Place Wher c ent ccurred in NewYork State:
`County OCity OVI OTown of . Perrnanent Landmark
`9 Road on which accident occurred
`(Houle Number or street Name)
`at 1) intersecting street
`a (Noute Number or Street Name)
`ON O
`or 2) OE OW of
`Feet Miles (Mdepost.Nearest intersectingRoute Number or Street Name)
`2tLHowdid the accident happen?
`27
`8. which Veh. 9. Position 10. Safety 12, 13. 16. injury If Deceased, Enter
`N meso Persons Involved O upied in/on Vehicle Equip.L Age Sex A B C Describe Injuries Date of Death
`Fl ?
`Identify DamagedProperty ViN
`Other Than Vehide(s)
`Nameof Insurance Company PolicyThal Issued Policy For Vehicle 1 Number 29Nameand Address of Policy Period
`Policy Holder From To
`If Vehicle was Operated Under Permit Nameand Address
`(ICC. USDOTor NYSDOT). give No. of Permit Holder
`- If Self-Insured, give and State 30Certificate No.
`to Print Nameof Driver Signature of Driver
`(or Representalwe (or Representative*)
`of Vehide 1 of Vehide 1
`* A rep s tive maysign for the driver if the driver is unable to sign Injurybecause of injury or death. If you are signing as the driver's representative,
`check the box that describes whythe driver cannot sign. Death
`FILED: NEW YORK COUNTY CLERK 06/17/2025 11:51 AMINDEX NO. 156383/2024
`NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 06/17/2025
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