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eCLAIM Receipt

You have successfully filed your claim.

By successfully filing your claim, you have certified that all information provided is true and correct to
the best of your knowledge and belief. You also understand that the willful making of any false
statement of material fact herein may subject you to criminal penalties and civil liabilities.

Please allow up to 30 days to receive an email acknowledging your claim.

If you have any questions please contact 212-669-3916.

Your Receipt Number is the following:

201800044275

You uploaded:
Claim Form: 1
Supporting Documents:0

5/9/2018 5:41 PM
Claimant Last Name:Terrell
Claimant First Name:David
Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer
Form Version: NYC-COMPT-BLA-PI1-D

Personal Injury Claim Form


Electronically filed claims must be filed at the NYC Comptroller's Website. If your claim is not resolved
within 1 year and 90 days from the date of occurrence you must start legal action to preserve your rights.

I am filing: C On behalf of myself. (.."' Attorney is filing.


On behalf of someone else. If on someone else's Attorney Information (If claimant is represented by attorney)
behalf, please provide the following information.
Firm or Last Name: The Sanders Firm, P.C.
Last Name:
Firm or First Name:
First Name:
Address: 30 Wall Street
Relationship to
the claimant: Address 2: 8th Floor
City: New York

Claimant Information State: NEW YORK


Zip Code: 10005
*Last Name: Terrell
Tax ID:
*First Name: David
Phone #: (212) 652-2782
*Address:
*Email Address:
Address 2:
*Retype Email
*City: Address:
*State: NEW YORK
The time and place where the claim arose
*Zip Code:
*Date of Incident: 04/27/2018 Format: MM/DD/YYYY
*Country: USA
Time of Incident: Format: HH:MM AM/PM
Date of Birth: Format: MM/DD/YYYY
*Location of NYPD Medical Division
Soc. Sec. # Incident:
HICN:
(Medicare #)
Date of Death: Format: MM/DD/YYYY
Phone:
*Email Address:
*Retype Email
Address:
Occupation: NYPD Detective
City Employee? (i' Yes C No C NA
Gender Ci Male C' Female ' Other

Address: One Lefrak City Plaza


Address 2:
City:
*State: NEW YORK
Borough: QUEENS
*Denotes required fields. A Claimant OR an Attorney EmailAddress is required.
Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer

*Manner in which
claim arose: Claimant alleges that since his appointment to the Department on July 1, 2002, he has been subjected to the
'random drug testing program.'

Claimant alleges that the Department administers the 'random drug testing program' under the guise of the 'public
safety sensitive position' exception.

Claimant alleges that the Department administers the 'random drug testing program' under threat of suspension
and termination.

Claimant alleges that under Department guidelines, the employee 'must' report and provide a urine and/or hair
sample.

Claimant alleges that under Department guidelines, the employee 'cannot' challenge the 'veracity' of the results to
the detriment of African-Americans and other officers of color.

Claimant alleges that the Department 'claims' the 'random drug testing program' computer algorithm doesn't
include an employees' race or national origin.

Claimant alleges that the Department manages the 'random drug testing program' using a computer algorithm
created and/or maintained by the Medical Division.

Claimant alleges that the Department through the Medical Division 'manipulates' the 'random drug testing
program' using a computer algorithm intentionally testing African-American and other officers of color more often
than similarly situated Caucasian officers.

Claimant alleges that the Department through the Medical Division have tested more African-American and other
officers of color meanwhile, failed to test similarly situated Caucasian officers.

Claimant alleges that the Department through the Medical Division uses the 'random drug testing program' to
intentionally discriminate against African-American and other officers of color in favor of similarly situated
Caucasian officers.

Claimant alleges that the Department through the Medical Division use of the 'random drug testing program' have
a 'disparate impact' upon African-American and other officers of color in favor of similarly situated Caucasian
officers.

Claimant alleges that the Department through the Medical Division use the 'random drug testing program' to
retaliate against African-American and other officers of color whenever they complain about discrimination and
other serious misconduct in the workplace.

Claimant alleges since July 1, 2002, he has been tested numerous times under the 'random drug testing program'
meanwhile other similarly situated Caucasian officers have never been tested.

Claimant alleges that on or about September 23, 2017, March 15, 2018 and April 27, 2018, the Department with
knowledge of the his filing a Notice of Claim, EEOC Charge of Discrimination and federal civil rights lawsuit, under
the guise of the 'random drug testing program' retaliated against him subjecting him to further testing.

*Denotes required field.


Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer

The items of $5 Million Dollars (Pain and Suffering, Mental Anguish and Punitive Damages)
damage or injuries
claimed are
(include dollar
amounts):
Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer

Medical Information Witness 1Information

1st Treatment Date: Format: MM/DD/YYYY Last Name:


Hospital/Name: First Name:
Address: Address
Address 2: Address 2:
City: City:
State: State:
Zip Code: Zip Code: Phone:
Date Treated in Format: MM/DD/YYYY
Witness 2 Information
Emergency Room:
Was claimant taken to hospital by ' Yes C' No t . NA Last Name:
an ambulance?
First Name:
Employment Information (If claiming lost wages) Address
Employer's Name: Address 2:
Address City:
Address 2: State:
City: Zip Code: Phone:
State: Witness 3 Information
Zip Code:
Last Name:
Work Days Lost:
First Name:
Amount Earned
Weekly: Address
Address 2:
Treating Physician Information
City:
Last Name:
State:
First Name:
Zip Code: Phone:
Address:
Address 2: Witness 4 Information

City: Last Name:


State: First Name:
Zip Code: Address
Address 2:
City:
State:
Zip Code: Phone:
Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer

Complete if claim involves a NYC vehicle

Owner of vehicle claimant was traveling in Non-City vehicle driver

Last Name: Last Name:


First Name: First Name:
Address Address
Address 2: Address 2:
City: City:
State: State:
Zip Code: Zip Code:

Insurance Information Non-City vehicle information

Insurance Company Make, Model, Year


Name: of Vehicle:
Address Plate #:
Address 2: VIN #:
City: City vehicle information
State:
Plate #:
Zip Code:
Policy #:
Phone #: City Driver Last
Name:
Description of Driver C Passenger City Driver First
claimant: Name:
Pedestrian C' Bicyclist
Motorcyclist 6 Other
C
Total Amount Format: Do not include "$" or ",".
$5,000,000.00
Claimed:

The Total Amount Claimed can only be entered once the following
required fields are entered:

Claimant Last Name


Claimant First Name
Claimant Address,City,State,Zip Code, and Country
Claimant Email or Attorney Email
Date ofIncident
Location ofIncident (including State)
Manner in which claim arose

I certify that all information contained in this notice is true and correct to the best ofmy knowledge and belief I understand that the willful
making ofany false statement ofmaterial fact herein will subject me to criminalpenalties and civil liabilities.