Fill and Sign the Declaratory Judgment Coverage Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF )       ) ) V. ) NO.       ) ) NAME OF DEFENDANT )       ) INDIVIDUALLY AND IN HER CAPACITY AS ADMINISTRATRIX OF THE ESTATE OF _____________ ) ) ) COMPLAINT COMES NOW ___________, pursuant to 2S U.S.C. Section 2201 and Rule 57 of the Federal Rules of Civil Procedure, and files this action for a declaratory judgment against __________, individually and in her official capacity as Administratrix of the Estate of __________. Plaintiff asks this court to declare the legal rights of the parties with respect to the insurance policy described below, and in support of its action for a declaratory judgment states as follows: 1. Plaintiff ___________ is a corporation incorporated under the laws of the State of ___________ and its principal place of business is in the State of __________. Defendant ___________ is an adult resident citizen of the State of ___________, whose address is __________, _________, _________. 2. This court has diversity jurisdiction over the parties to this action pursuant to 28 U.S.C. Section 1332 because the parties are resident citizens of different states and the matter in controversy exceeds the sum of $75,000, exclusive of interest and costs. Venue is proper in the ____________ District of ___________, _________ Division. 3. On or about __________ __, ____, _______ executed a Retail Installment Contract with __________ in ____________, ____________ for the purchase of a _________ truck bearing vehicle identification no. _________. ______________ was the co - buyer to this contract. Said contract was subsequently assigned to __________. Attached hereto as Exhibit "A" is a copy of the Retail Installment Contract. 4. In connection with the purchase of said vehicle, _________ and _________ applied for a credit life insurance policy with the plaintiff, which proposed to pay amounts due on the Retail Installment Contract up to $________.___. See Exhibit "A"; see also Franchise Creditor Insurance Certificate, attached hereto as Exhibit "B". 5. The "Eligibility Statement" in Exhibit "B" provides: To the best of my knowledge and belief, during the past three years I have not been treated for, diagnosed, nor have I been advised to have treatment for any of the following: ... diabetes ... I have not been confined in a hospital or institution during the preceding six (6) months for the aforementioned conditions. ... I understand that to be eligible for the insurance applied for, the foregoing representations must be true to the best of my knowledge and shall, in the absence of fraud, be deemed representations and not warranties, and if same not be true, that I am not eligible for insurance for which application is made, and the company's liability is limited to a return of the premium. ... 6. The Certificate was signed by ___________, as the insured debtor, along with _____________, as the joint debtor, under the statement that "I/we have read and understand the above Eligibility Statement, and understand that this certificate shall be null and void if such representations are false." Said application was witnessed by ___________, an employee of _____________. 7. On _____________ __, ____, ___________ died. Her/His Certificate of Death is attached hereto as Exhibit "C". 8. _______________ subsequently presented a claim under the policy __________ then obtained medical records in connection with the treatment of Mr. ___________ immediately prior to his death. Said records clearly revealed that Mr. __________ had a "history of insulin dependent diabetes mellitus". 9. Accordingly, ____________ disclaimed coverage based on ___________'s misrepresentation regarding his diabetic condition. _______________ simultaneously returned the portion of the insurance premiums representing life insurance on the life of ___________ to the credit of the _____________ account, provided by the certificate. However, ________ has kept the coverage in force with respect to the life of ____________. There is nothing in the insurance certificate that would permit ___________ to disclaim, rescind or cancel the life insurance coverage on the life of ___________. ___________ does not have any knowledge or information that there were any misrepresentations on the eligibility statement in regard to __________’s medical history or eligibility. Neither__________ or her counsel requested or demanded a return of the premium until after the coverage on her life expired and she is stopped to now assert that same did not want the insurance coverage on her life. 10. ______________ alleges that under the express terms of the policy and due to the material misrepresentation by ___________, it was entitled to disclaim coverage on the life of __________ on the information revealed in medical records of his last illness. 11. That on _____________ __, ____, __________ made demand on ________ to pay $_______.____, the amount that would have been due under the Franchise Creditor Insurance Certificate if coverage had been in effect; a return of the portion of the premium for the insurance on the life of ___________; additional compensatory damages and punitive damages in a sum exceeding $________._____. __________ denies that it is indebted to the Estate of ___________ or ____________ in any amount whatsoever and asks this court to declare the rights of __________, the Estate of __________ and _________. WHEREFORE, _______________ prays as follows: A. That the court enter a declaratory judgment adjudicating that _________ was entitled to disclaim coverage on the basis that the portion of the policy insuring the life of _________ was null and void due to his material misrepresentation; B. That the court enter a declaratory judgment adjudicating that the insurance coverage on the life of ___________ remained in force and effect according to its terms, could not be rescinded based upon misrepresentations by _____________ on the eligibility statement and that ___________ is not entitled to a return of the premium paid for the coverage on the life of _____________; C. _______________ prays for any other relief that would be right and proper under the circumstances; and D. That ________________ be awarded its costs incurred herein and such other relief as may be warranted. Respectfully submitted, _______________________________