Fill and Sign the Amended Complaint Form 497426603

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) AMENDED COMPLAINT COME NOW plaintiffs _______________________ and _____________________, through counsel, and file this Amended Complaint against ________________________ and _____________________ and in support thereof set forth the following: 1. __________________________ is an adult resident citizen of _____________ County, ______________, residing at ____________________________________________. 2. __________________________ is an adult resident citizen of _____________ County, ______________, residing at ____________________________________________. 3. ______________________, whose home office is located in _______________, ___________, is licensed to sell insurance in the State of _____________. _________________ is a real party in interest under Rule ______, _______________ Rules Civ. Pro., due to its subrogation lien for medical payments. 4. Defendant ____________________ is a _________________ Corporation, licensed and doing business in the State of ___________________, who may be served with process through its agent, ______________________. - 1 - 5. Defendant _________________________ was the agent, servant and employee of defendant __________________________. 6. During all the times herein mentioned, defendant _____________________ was the owner of an eighteen wheel Mack truck, which at the time of the accident hereinafter described was being driven by ________________________, an employee of defendant _________________________, during the course and scope of his employment for _________________________, with the express permission and consent and for the benefit of _________________________. 7. As a result, defendant ___________________ is responsible both for _____________________’s actions and conduct pursuant to the doctrine of respondent superior and for any negligence of its own. 8. On the _____ day of ____________, 20___, at about ______ a.m./p.m., the plaintiff ______________________ was operating an automobile owned by her in a __________ direction on ________________ road/highway in _____________ County, _____________, approaching ______________. 9. At said intersection is a traffic control signal. As plaintiff _______________ approached, it turned red and she brought her car to a stop. 10. Defendant _________________ approached the plaintiff's car from behind and failed to stop, suddenly and violently striking the plaintiffs' car from the rear. 11. Said collision was the proximate cause of property damage to plaintiff's car, temporary injuries to plaintiff ___________________, and serious and permanent injuries to plaintiff ____________________. - 2 - 12. Plaintiff __________________ at all times during the occurrence hereinbefore set forth used due care and caution and was completely free from any and all negligence in any manner contributing to his/her injuries and damages as herein complained of. 13. Said collision was due to defendant __________________'s negligence in that he was not keeping a reasonable lookout, did not have his truck under proper control and was otherwise guilty of carelessness and negligence in the operation of that motor vehicle. 14. Plaintiffs allege that the proximate cause of the aforementioned collision was the negligence of defendant _____________________, for which negligence he must stand responsible together with his employer, jointly and severally, said negligence including, but not limited to, the following acts and omissions: a. Failure to keep a proper lookout; b. Failure to maintain a safe speed; c. Any and all other negligent acts and/or omissions which may be shown during the course of these proceedings. 15. Plaintiffs allege that the proximate cause of the aforesaid collision was the negligence of defendant __________________ and for which negligence it must stand responsible, said negligence including, but not limited to, the following acts and omissions: a. Negligent entrustment of an oversized motor vehicle; and b. Any and all other negligent acts and/or omissions which may be shown during the course of these proceedings . 16. As a result of the aforesaid collision, plaintiff __________________ suffered physical injuries requiring medical treatment, and plaintiff __________________ suffered temporary total disability and partial permanent disability. - 3 - 17. As a result of the aforesaid collision, plaintiff ____________________ suffered emotional trauma and distress and incurred expenses and lost income. 18. As a result of the aforesaid collision, plaintiff _____________________ will continue to suffer the aforesaid damages and, further, will continue to incur medical expenses in the future. 19. Because of the injuries suffered in the collision by his wife, plaintiff ___________________ has lost and been deprived of the services of his wife, including loss of society, companionship, consortium, and he will continue to be permanently so deprived of as a result of the injuries suffered by plaintiff ____________________________. 20. _____________________ is plaintiff's med - pay insurance carrier and has placed plaintiff on notice of its subrogation lien in the amount of $____________, to date. It is joined as a real party in interest pursuant to Rule _______, ____________ Rules Civ. P. WHEREFORE, PREMISES CONSIDERED, plaintiffs pray that defendants, _____________________ and ____________________ each be served with process of this Court, to appear and answer same, and that after due proceedings be had there be judgment herein in favor of plaintiffs and against defendants, jointly and severally, in the amount of ________________________ Dollars ($________) with interest from the date of judicial demand until paid, for all costs of these proceedings and for any and all other legal and equitable relief to which they may be entitled. And, plaintiffs pray for general relief. Respectfully submitted, Dated: - 4 - Name:       Title:       Address:       Address:       City, State, Zip:       Phone:       Fax:       E-Mail:       Attorney No.:       CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. - 5 -