Fill and Sign the Complaint Pay Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF )       ) ) V. ) NO.       ) ) NAME OF DEFENDANT )       ) ) COMPLAINT JURY TRIAL REQUESTED COMES NOW, the Plaintiff, _____________, by and through his attorney and files this his cause of action against the Defendant, ____________, (hereinafter referred to as "______________") and in support of his cause of action, states as follows: I. The Plaintiff is an adult resident citizen of ______________ County, ______________. II. The Defendant is a corporation organized and existing under the laws of a state other than the State of ______________ and is qualified to do business in the State of ______________ as foreign corporation. The registered agent for service of process for ______________ is ______________, ______________, ____________________________ and the Insurance Commissioner of the State of ______________. III. This Court has jurisdiction of the parties and subject matter. IV. On or about ________________ __, ____, the Plaintiff, ______________, was injured in an automobile accident. V. The Plaintiff purchased a policy from ____________, being policy numbers ______________ and ______________ which included medical payment coverage of _______________/______ ($________._____) on each policy of insurance. VI. The Plaintiff, ______________, has incurred medical bills of $______________ due to this accident. A copy of the Medical Bills Summary is attached as Exhibit "A" and incorporated herein by reference as if set forth in full in words and figures. VII. On numerous occasions counsel for the Plaintiff has corresponded with the Defendant, but the Defendant has wholly failed and refused to pay said benefits. VIII. At all material times hereto, the required premium, on the above policy, for said insurance was paid to the Defendant. IX. As a direct and proximate result of the conduct of the tortfeasor, the Plaintiff has sustained losses, including benefits withheld and expenses of litigation and have suffered other damages, all to the Plaintiff detriment and damage in such sums as are owed by the Defendant by law and as may be determined by a jury at the trial of this cause. WHEREFORE, PREMISES CONSIDERED, Plaintiff prays that this Complaint be received and filed and that upon trial by jury of this cause, judgment in the amount ________ and No/________ Dollars ($______.____) actual damages or an amount of damages to be determined by the jury, within the jurisdiction of this Court, be entered jointly and severally against the Defendant. Plaintiff further prays that he be awarded pre and post judgment interest, costs, attorney's fees and such other and further relief to which he may be entitled. Respectfully submitted, ________________________________