Fill and Sign the Complaint Injury Form

IN THE CIRCUIT COURT OF_________ COUNTY, ____________ NAME OF PLAINTIFF )       ) ) V. ) NO. ) ) NAME OF DEFENDANT )       ) ) COMPLAINT Plaintiff, ________, files her Complaint against Defendant, ________ and in support thereof states as follows: 1. Plaintiff is an adult resident citizen of the state of ________ residing at ________, ________ County, ________. 2. Defendant, ________, is a ________ corporation and may be served by serving a copy of this Complaint and Summons on its registered agent for service of process, ________. 3. On ________ Plaintiff, ________ was in the ________ Store, also known as ________, located on ________ Drive in ________ County, ________. ________ was at the store as a customer and was shopping for household items. 4. While walking through the store on that day Plaintiff, ________ slipped on some water that was on the floor adjacent to a cooler containing bags of ice. Plaintiff fell and was seriously injured. 5. Defendant negligently failed to remove the water from the floor, negligently failed to adequately warn the Plaintiff of the concealed defect and otherwise negligently caused Plaintiffs' injuries. 6. - 1 - As a proximate result of Defendant's negligence, Plaintiff, ________, suffered personal injuries including physical pain, mental pain and suffering, past and future medical expenses, lost wages and loss of wage earning capacity. WHEREFORE, Plaintiff demands judgment from the Defendant in the sum of no less than _______________ and 00/100 Dollars ($00.00) with pre - judgment interest from the date of judicial demand, interest on the judgment at the legal rate until paid, and costs of court. THE PLAINTIFF HEREBY DEMANDS TRIAL BY JURY Respectfully submitted this the _____ day of ____________ 20____. ATTORNEYS FOR PLAINTIFFS OF COUNSEL: - 2 -