Petition for Worker’s Compensation Benefits

Court Petition, Order, Complaint, and Certificate of Service

IN THE COURT OF COUNTY
STATE OF

Petitioner/Plaintiff:

Respondent/Defendant:

Case No.:

PETITION TO THE HONORABLE JUDGES OF THE COURT OF ,

Comes now the Plaintiff, , and shows unto Your Honor that on the day of , , Plaintiff was an employee as defined by the Worker's Compensation law and that her employer was Company, a corporation which was doing business in County, at said time.

Plaintiff shows that he/she suffered injuries on or about the day of , while acting within the line and scope of her employment; that she suffered temporary total disability as a result of this accident; that his/her employer has not paid to her the total compensation and medical benefits to which she is entitled for the time she has been temporarily totally disabled and has failed and refused to compensate Plaintiff for the benefits to which she is entitled pursuant to the Worker's Compensation law.

Plaintiff prays for permission to secure the services of attorneys to represent her in this matter and requests permission to secure the services of , Attorney at Law, .

STATE OF

COUNTY OF

I, the undersigned Notary Public in and for said State and County, certify that , whose name is signed to the foregoing Petition and who is known to me, acknowledged before me on this day that, being informed of the contents of said instrument she voluntarily executed same on this day of , .

Given under my hand and notarial seal this day of , .

________________________________________

NOTARY PUBLIC, STATE OF

My Commission Expires:

ORDER

The Petition of in the above styled cause seeking permission to secure the services of an attorney to represent her in said cause having been submitted to the Court, and the Court being of the opinion that said permission should be granted, said is hereby permitted and authorized to employ the firm of , to represent her in her claim for injuries arising out of the accident she sustained in the line and scope of her employment on the day of , while employed by Defendant, Company on the day and date of alleged injury.

DATED this day of , .

___________________________
CIRCUIT JUDGE

COMPLAINT

FIRST CAUSE OF ACTION

Comes now, the Plaintiff, , and shows unto the Court as follows:

1. On or about the day of , , was a resident citizen of County, and was a workman or employee of Defendant Company, which was at all times material herein doing business in County, State of .

2. While so employed and while working within the line and scope of her employment as an employee of Defendant, Plaintiff was injured as follows:

a)

b)

c)

3. Plaintiff avers that her injuries arose while in the line and scope of her employment and as a proximate result thereof, she was temporarily totally disabled.

4. Plaintiff's average weekly earnings at the time of said accident and for a period of time prior to, had been no less than $.

5. Defendant was given prompt and actual notice of said accident within () days of the occurrence thereof, as specified by the Worker's Compensation Act of the State of .

6. A dispute and controversy has arisen in that Defendant has refused to pay full compensation and medical benefits due to Plaintiff under the Worker's Compensation Act of the State of .

Wherefore, Plaintiff demands judgment against Defendant for the compensation and medical benefits to which she is entitled Under the Worker's Compensation Act of the State of .

SECOND CAUSE OF ACTION

7. Plaintiff adopts and realleges the allegations contained in paragraphs One through Six as have been previously and fully set out herein.

8. On or about the day of , , after Plaintiff was injured while working within the line and scope of her employment as an employee of Defendant, Plaintiff was terminated from her employment with the Defendant.

9. Plaintiff was terminated by Defendant solely because Plaintiff filed a claim and sought recovery of worker's compensation benefits under the Worker's Compensation Act prior to her termination.

10. The Plaintiff's termination by Defendant was in violation of § , Code of , and in retaliation for her claim for recovery under the Worker's Compensation Act.

11. As a proximate consequence of Defendant's actions and the termination of Plaintiff's employment, Plaintiff has caused to suffer the loss of wages, and suffer emotional distress and mental anguish by the actions of the Defendant.

Wherefore, Plaintiff demands judgment against Defendant for both compensatory and punitive damages, plus interest and costs.

Respectfully submitted,

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 , .

_________________________________
Attorney

PLAINTIFF DEMANDS A TRIAL BY JURY ON THE SECOND CAUSE OF ACTION

____________________________________

DEFENDANT IS TO BE SERVED BY CERTIFIED MAIL AS FOLLOWS:

Service Line 1:

Service Line 2:

Service Line 3:

I acknowledge the jury demand on the second cause of action.