Fill and Sign the Declaratory Judgment Form

JOHN LAWYER, ESQ. 12 MAIN STREET ANYWHERE, USA Attorney for Plaintiffs -------------------------------X JANE DOE, : SUPERIOR COURT OF NEW JERSEY : LAW DIVISION Plaintiff, : [INSERT] COUNTY : : DOCKET NO.: : : Civil Action vs. : : ABC SECURITY LIFE : COMPLAINT AND JURY DEMAND INSURANCE COMPANY, and : SECURITY-123 LIFE : INSURANCE COMPANY, and XYZ : CORPORATION, a fictitious name, : : Defendants. : -------------------------------X The plaintiff, Jane Doe, residing in [insert address], by way of Complaint against the defendants, allege and say: FIRST COUNT 1. At all times relevant hereto, the defendant, ABC Security Life Insurance Company is a corporation licensed to do business in the State of [insert] as an insurance company, providing life insurance for individuals. 2. Security-123 Life Insurance Company, upon information and belief, is the corporate parent of the defendant corporation, ABC Security Life Insurance Company. 3. XYZ Inc. (a fictitious name) is named in the event that the proper name for either of the above referenced corporations is other than as represented above. 4. At all times relevant hereto, the plaintiff is the owner of a policy of insurance issued by the defendants on the life of John Doe, which policy of insurance was originated and is dated as of [insert date]. Said policy of insurance contains an expiration date of [insert date]. A copy of the policy is attached hereto as Exhibit A and is incorporated herein by this reference. 5. Paragraph [insert] of the application for the aforesaid policy, which application is made a part of the policy as shown in Exhibit A, provides that premium notices for the life insurance policy herein question are to be sent to the Owner unless otherwise indicated. 6. The Owner of the aforesaid policy is identified, at paragraph [insert] of the application, as referenced above, which owner is shown to be the plaintiff, Jane Doe. 7. At no time has the Owner of the aforesaid policy been changed, although the reference to the Owner was amended on [insert date] to indicate that the accurate name and address of the Owner of the policy was Jane Doe, [insert address]. 8. On or about [insert date], the individual whose life was insured by said Policy, John Doe, died. Said death constituted a loss falling within the terms of the coverage of the aforesaid Policy. 9. On or about [insert date], the plaintiff Jane Doe, had telephone contact with the agent, employee and/or representative of the defendant, ABC Security Life Insurance Company, by the name of [insert name]. The plaintiff, Jane Doe, thereby gave notice to and otherwise advised the aforesaid agent, employee and/or representative of the defendant, ABC Security Life Ins. Co. of the death of John Doe. 10. Defendants have denied coverage under the aforesaid Policy based upon the assertion of non-payment of premium. 11. A controversy exists between the parties concerning their respective rights under the Policy as follows: (a) The defendants contend that, pursuant to a notice received by the defendant, ABC Security Life Insurance Company on or about [insert date], a change of address for the purpose of premium notification was filed with regard to the aforesaid Policy. A copy of the alleged change of address for premium notification is attached hereto as Exhibit B. (b) Defendants further contend that the Policy effectively lapsed for non- payment of premium, which premium was due and owing as of [insert date]. (c) Plaintiff contends that, pursuant to the terms of the Policy, plaintiff was to receive premium notices sent directly to her, which notices were not forthcoming from the defendants. (d) Plaintiff further contends that the aforementioned alleged change of address notification was invalid and unauthorized; and that the defendants knew or should have known that it was invalid and/or unauthorized since plaintiff = s signature does not appear anywhere on that form. (e) Plaintiff further contends that defendants never provided her with a notice of non-payment of premium, and, furthermore, failed to provide her with the promised premium notices as required according to the Policy of insurance. By reason of the foregoing, a declaratory judgment is both necessary and proper in order to set forth and determine the rights, obligations and liabilities that exist between the parties in connection with the aforementioned Policy. WHEREFORE, plaintiff respectfully requests the Court enter judgment as follows: 1. Declaring that the aforementioned insurance policy between the plaintiff and the defendant(s) was in full force and effect as of the date of the insured = s, John Doe = s, death, [insert date]; 2. Declaring the rights and other legal obligations of the plaintiff and the defendant arising under the aforementioned insurance Policy; 3. Awarding plaintiff the costs and reasonable attorneys fees incurred in pursuit of this action; and 4. Awarding such other and further relief as the Court deems just, proper and equitable under the circumstances. SECOND COUNT 1. Plaintiff, Jane Doe repeats each and every allegation contained in the First Count of the plaintiff = s complaint and incorporates them herein as if set forth at length. 2. Defendant has breached the duty of good faith and fair dealing implied in the Policy, a contract of insurance. 3. The defendants have acted in bad faith in denying the plaintiff the benefit of the aforesaid Policy, the proceeds of which she requires for her maintenance and sustenance. WHEREFORE, plaintiff demands judgment against the defendants: 1__ For compensatory damages; 2__ For punitive damages; 3__ For interest, costs of suit and counsel fees; and, 4__ For such other relief as the Court may deem just, proper and equitable under the circumstances. JURY DEMAND Plaintiffs hereby demand a trial by jury as to all issues. DESIGNATION OF TRIAL COUNSEL John Lawyer, Esq., is hereby designated as trial counsel in this matter. CERTIFICATION I hereby certify pursuant to Rule 4:5-1 that this matter is not the subject of any other action pending in any Court or of a pending arbitration proceeding, and that there exist no other parties to be joined to this action. Dated: __________________________________ JOHN LAWYER