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Home My WebLink About04-0215Cindy L. McClucas-Herman Plaintiff Big Dog Auto Sales, Inc. Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Civil Action - Law PRAECIPE FOR ENTRY OF DEFAULT JUDGMENT PURSUANT TO SECTION 428 OF THE WORKERS' COMPENSATION ACT, 77 P.S. §921 Pursuant to section 428 of the Workers' Compensation Act, 77 P.S. 921, enter judgment against Defendant in the amount of $30,000.00, based upon the following: 1. Plaintiff has filed a Claim Petition for Workers' Compensation, and a Petition for Penalties with the Bureau of Workers' Compensation. Disposition of those petitions is pending. Certified copies of the two petitions are being filed currently with this praecipe. 2. The assignment notice issued by the Bureau of Workers' Compensation states that "Insurance coverage could not be determined." Therefore, upon information and belief, Plaintiffhas concluded that Defendant does not carrier Workers' Compensation Insurance. 3. Section 428 of the Workers' Compensation Act, authorizes the entry ora protective judgment against an employer who has not complied with the statutory mandate to obtain Workers' Compensation insurance for the protection of its employees in the event of work related injury. Respectfully submitted, The Wellington 17 E High St STE 101 Carlisle PA 17013-3047 (717) 249-4500 AFFIDAVIT I verify that I have personal knowledge of all facts not of record set forth in the foregoing Praecipe, and that such facts are true and correct, to the best of my knowledge, information, and belief. I acknowledge that any false statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unswom falsification to authorities. Fred H. Halt HAlT & PUHALA, P.C. ATTORNEYS AT LAW Workers' Compensation - Employment Discrimination -Personal Injury THE WELLINGTON 17 East High Street, Suite 101 Carlisle, Pennsylvania 17013-3047 Ph: (717) 249-4500 Fx: (717) 249-2411 pajoblawfh~earthlink.net 12/17/03 BRANCH OFFICE Chambersburg: (717) 263-7344 Files Division Bureau of Workers' Compensation 1171 South Cameron Street, Room 103 Harrisburg, PA 17104-2501 ~:~e~.I4 Ml:Che~,Herman~v. Big Dog Auto Sales, Inc. Bureau Claim No. 2575238 To Whom It May Concern: We represent the Claimant in this pending matter. The Assignment Notice for the Claim Petition indicates that insurance coverage could not be determined. Therefore, please provide us wi~~ of the Claim Petition and the Notice of Assignment of the Claim Petition,~{~e can enter a protective judgment against the employer pursuant to section 428 of the Act. Thank you. Cc: CindyL. McClucas-Herman LABOR & INDUSTRY DE[; 1 9 2003 CLAIMS MANAGEMENT Bureau of Workers' Comp. Received BWC 2003-i2-01 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT,OF LABOR AND INDUSTRY B URE.~U OF WORKERS' COMPENSATION 11171 $, CAMERON STREET, ROOM 103 HARRISBURG, PA 171~4-2501 {TOLL FREE) 800-482-2383 TTY 8oo-362-4228 PETITION FOR PENALTIES SociN Secur~b/Number: - Date~flnjup/: 08 / 21 /2.003 PA BWC Claim Number:. Employee Employer F~ N;,~ r~ ,~ Big 009 A~to Sales, Inc. Cindy t. McClucas-Herman ~r..~ 1073 Harrisburg Pike Lot · 29, Bailey Run Newport PA 17074 * Ca~isle PA 17013 - c~r~ *r,,~ Cumberland Perry (717> 567 * 6695 (717)258 -0363 Injury VS. Insurer or Third Party Administrator (if self-insured) Neck and back injuries $~reet 2 PLEASE ENTER MY APPEARANCE FOR PETmONER: Attorney Counael for Respondent (If known) Fred H. Halt Halt & Puhala, P.C. Th~ Wellington 17 _East High Street, Suite 101 Cadjsle PA 17013 - 3047 (717) 249- 4500 34331 { ) NOTICE: This petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left comer. LIBC.~686 REV ~02 (OVER) Received BWC 2003-12-01 1. The aforementioned Employee, or hi~/her Representative, Attorney Fred H. Halt -, believes that the aforementioned Insurer, TPA, or Self-insured Employer has violated the terms of the Workers' Compensation Act and/or Regulations in the processing or payment of compensation to the Employee(s) in that: (Specie. in detail, the nature of the alleged violation(s) and the Section of the Law/Regulation which applies. Attach an additional sheet, if necessary.) a. Respondent violated section 406.1 of the Workers' Compensation Act by failing to issue Notice of Compensation Payable, Notice of Temporary Compensation Payable, or Notice of Workers' Compensation Denial within 21 days of notice of the injury, b. Respondent violated sect~bn 1102(8) of the Workers' Compensation Act by misrepresenting to Petitioner that part time employees are not covered by Workers' Compensation. This misrepresentation was done with the intent to prevent Petitioner from pursuing a claim for her injuries. c. Petitio~ mquesta asse%sment ~ counsel ieee pu~uan%.to section 440 in the event of unreasonable contest by Respondent, Further, the Employee requests that the Insurer, TPA, or Self-insured Employer be required to pay penalties in the total amount of $ . . . which represents 50% percentage of the compensation to which the Employee was entitled, but X not paid which was paid late for the period from 08 / 21 / 2003 to illegally suspended WHEREFORE, the Employee requests that the Department of Labor and Industry require the Insurer, TPA, or Self-insured Employer to answer this Petition within twenty(20) days of sar~ice of this Petition on the adverse parties as provided for by Section 416 of the Workers' Compensation Act, and to schedule such hearings as are necessary to determine and gre~t the relief requested in the previously mentioned paragraphs. DATE OF THIS NOTICE: /,/I ~-~/ 0.3 Petitioner Cindy L, McClucas-Herman Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. ~Rece~ved BWC 2003-12-01 Received BWC 2003-12-01 3'TY 800-362~228 CLAIM PET[Ti~)N FOR WORKERS' COMPENSATION 08/21/2003 EMPLOYEE First Name Cindy L, Last Name McClucas-Herman If Deceased - Dependent or Guardian First Name Last Name Address Lot # 29, Bailey Run Address r City/Town Newport County Per~ Tek, phone 7175676695 Stare PA Zip 17074 .E_MPLOYER Name Big Dog Auto Sales. Inc. Ad.Vase 1073 Harrisburg Pike Address cityrrow~ Carlisle State PA zip 17013 County Cumberland Telephone 7172580363 rEIN VS, i.NS. URE-R ~r THIRD pARTYADMINI~TI~.TOR (if self-insuredi Name Add,ess Ad~e City/Town State Zip Telephone Bureau Cede County Claim # FEIN 1. Complete description of injury or illness including all parts of body affected. (~ ~u are seeki.g edd~aona compensation from the SubSequent injury Fund for total disability as a result of a previous permanent loss, or loss of use of one hand, one arm, one foot, one leg or one eye, end a sut3sequent Inju~y causing Jo~s, or Ios~ of use of, another hand, erin, foot, leg or eye, yo~ must alSO submit form I. rBC-375.) Neck and back injuries MONTH DAY 2. if occupational disease, give the last date of employment and/or last date of exposure 3. Give date of injury or onset of disease 08121/2003 4. How did the injury or disease happen? was involved in a motor vehicle collision in the course and scope of my employment 5. Did injury or disease occur on employer's premises? Harrisburg Pike at Wolf's 8ridge Road, Middlesex Twp, Cumberland County, PA Notice of your injury or disease was served on your employer on following manner: infon'ned George A. Montemayor, president of Big Dog Auto Sales, Inc, Yes x No Where? (Be specific.) 08/21/2003 7. What was your .~ob title at the time of injury or disease? LlBC.362 REV 4-02 (OVER) YEAR in the 362 1197-! R~eeived BWC ~003-12-01 ~.~e you working for more than one employer at the time of your injury? Yes x No If Yes, list additional e~p~ 9~ Did this problem cause you to stop working? x Yes No Il Yes, give date. 08125~003 10. Are you back to wo~ with the same employer? Yes x No If Yes, Regular Job Other Job / Give Title. 11. Are you wor~<ing with another employer? Yes x No If Yes, give name and address of new employer: 12. What were your wages at the time of injury? $ 7.00 XHour Day or Week 13. If you have returned to work since your injury or illness, are you earning More Same Less than,~3u ~e~e at the time of iniury? Current earnings $ Hour Day 14, I am seeking payment'for (ch~dE'AII that apply): .... Loss of wages padial disability f~om to Full disability from to x Medical bills (gk'e name of doctor/hospital, address, type of treatmen{ and bill in space below). Carlisle Regional Medical Center, Carlisle, PA x Counsel fees to be paid by the employer. Nicastre Chiropractic, Carlisle, PA Loss or loss of use of arm, hand, finger, fag, foot or toe. Disfigurement (scars) of head, faCe, or neck. or Week Loss of sight. Loss of ~5. Ot~er 16. Is there other pending litigation in this case? x Yes Penalty Petition ~pL~..ASE-E. NTER'M¥ ~NCE FOR PETI~IbNE~ ~ ~-~ - ~omey Name Fred H. Halt PA A~mW ID Numar ~331 Fi~ Na~ HaJt ~ PuhaJa, PC. Address The Welangton Address 17 East High Street, Suite 101 T~e 7172494500 ~e B~eau of Wo~' Compensation, 1171 South ~me~n st~t, Room 103, Har~, PA 171 ~2501. A ~ must ~ ~nt W ~u to the empl~er. In~ on ~e ~mp~ti~ of t~ te~ may be o~ined by Any individual ~[in~ mis~ading or in~mg~te ~o~o~ k~ a~ ~[th [~t~t to No If Yes, explain below: Cate of Petition A copy of this petit[on has~ been sent to the employer. "~ Signature x Emp~oye~ Atlomey llm !!!!llll ]Received BWC 2003-12-01 %00: %01:, %02 %03 %04 #05 %06: %07: %08: %09: %10 %11 %12 %13: %14: %15: %16: %17: %18: %19: %20: %21: %22: %23: %24: %25: %26: %27 %28 %30 %31 %32 %00 %02 %03 %O4 %06 %07 %08 %09 %10 %11 %12 %13 %15 %16 %17 %18 %19 %20 %21 %22 %23 %24 %25 %27 %28 %29 %30 %32 %33: %35: %36: %37: 12/03/03 08:05:56 efrantz 36211971' 2003108-21 CINDY L MCCLUCAS HERMAN LOT 29 BAILEY RUN NEWPORT PA 17074 PERRY 7175676695 BIG DOG AUTO SALES INC 1073 HARRISBURG PIKE CARLISLE PA 17013 CUMBERLAND 7172580363 2003-08-21 Y 2003-08-21 12/03/03 08:05:56 efrantz N Y 2003-08-25 Y N N Y N Y N N 7.00 Y N N N N N N N N 0.00 N N N 36211972 Y Y N LIBC-475 REV 6-01 Harrisburg, PA 1710~ BUI~AU OF WORKERS' COMPENSATION January 9, 2004 The foregoing is hereby certified to be a true and and correct copy of the record in the case of Cindy L. McClucas-Herman v. Big Dog Auto Sales Inc., BWC #2575238, D/I 8/21/03 as full, entire, and complete as the same remains on file in the Bureau of Workers' Compensation of the Department of Labor and Industry. Certified thi~ 9 th day of January 2004 Chief Claims Management Division I hereby certify that Nathaniel M. Holmes , who signed the foregoing, was at the time of siRninR, Chief, Claims Management Division, Bureau of Workers' Compensation, and ns such, was the legal custodian of the above*described records. IN TESTIMONY WHEREOF, I have hereunto set my hand and caused the seal of the Department of Labor and Industry to be affixed on this 9th d~yof January ,2004 Seal of the Department of Labor and Industry ~ Sandra J. Neal