Fill and Sign the Complant Work Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) PETITION TO THE HONORABLE JUDGES OF THE _______________ COURT OF _______________, _______________ COMES NOW the Plaintiff, _________________, and shows unto Your Honor that on the ______ day of ____________, 20___, 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 ____________, 20____, 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, ___________, _______________. - 1 - ________________________ ________________________ 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 ___________, 20___. Given under my hand and notarial seal this _____ day of ___________, 20___. ________________________________________ NOTARY PUBLIC, STATE OF _____________ My Commission Expires: ___________ - 2 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) 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 ____________, 20____, while employed by Defendant, _____________ Company on the day and date of alleged injury. DATED this_____ day of_____________, 20___. ___________________________ CIRCUIT JUDGE - 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT FIRST CAUSE OF ACTION COMES NOW, the Plaintiff, _________________, and shows unto the Court as follows: 1. On or about the ______ day of ____________, 20___, _____________________ 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) Plaintiff suffered injuries to both her arms that required medical treatment and will so in the future. b) Plaintiff was made sore and lame, suffered pain and will continue to do so; and c) Plaintiff suffered physical and mental anguish and will so in the future. - 1 - 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 __________, 20___, 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. - 2 - 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, Dated: Name:       Title:       Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 3 - 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____. _________________________________ PLAINTIFF DEMANDS A TRIAL BY JURY ON THE SECOND CAUSE OF ACTION ____________________________________ Attorney DEFENDANT IS TO BE SERVED BY CERTIFIED MAIL AS FOLLOWS: ________________ ________________ ________________ - 4 -