Fill and Sign the Insurance Contract Form

IN THE UNITED STATES DISTRICT COURT FOR THE __________________ DISTRICT OF _______________ , __________________ DIVISION __________________ PLAINTIFF V. CIVIL ACTION NO. __________________ __________________ DEFENDANT COMPLAINT Comes now __________________ , and files its Complaint against __________________ , Defendant, and in support hereof, Plaintiff would show unto the Court the following matters and facts: 1. Plaintiff, __________________ (hereinafter referred to as " __________________ ") is a corporation organized and existing under and pursuant to the laws of the State of __________________ , and which has its principal place of business in the City of __________________ in the State of __________________ . 2. Defendant, __________________ (herein after referred to as " __________________ "), is an agricultural association organized and existing under the laws of the State of __________________ , and which has its principal place of business in __________________ , __________________ . Process may be served upon __________________ by serving same on its President, __________________ , at the principal place of business of said Defendant, which is located at __________________________ , or by mailing said process in accordance with Rule 4(c) of the F.R.C.P. to said __________________ at the mailing address of Defendant: __________________________ . 3. This Court's jurisdiction is based upon diversity of citizenship pursuant to 28 U.S.C. § 1332. The amount in controversy herein is in excess of __________________________ Dollars ($ ____________ ), exclusive of interest and costs. Venue is properly placed under 28 U.S.C. § 1391. 4. That effective ____________ , _____ , __________________ entered into a Shared Fund Agreement with __________________ , regarding __________________ 's Group Insurance Policy No. _____ with __________________ . A copy of said Shared Fund Agreement is attached hereto as Exhibit "A" and made a part hereof. Said Agreement was entered into by __________________ for the purpose of providing medical benefits to eligible employees of __________________ . 5. That pursuant to said Agreement, __________________ assumed liability for funding medical benefits payable under the policy subject to a maximum amount as described in said Shared Fund Agreement. Pursuant to said Shared Fund Agreement, __________________ agreed to process and pay medical benefits due under said Group Policy and Shared Fund Agreement and pay medical benefits, if any, which exceeded the maximum amount described in said Shared Fund Agreement in return for premiums to be paid by __________________ to __________________ as provided in said Shared Fund Agreement and Group Insurance Policy No. _____ . 6. The Shared Fund Agreement was developed by __________________ as an alternative to a conventional group insurance policy or employer self-insured program. The purpose of a shared fund agreement is to provide a fully insured health insurance agreement while providing to the policyholder cash flow advantages as well as limiting the premium tax charges to only those premiums which __________________ pays on claims funded by __________________ . 7. Pursuant to said Shared Fund Agreement and predecessor agreements with __________________ , said Defendant established a bank account with __________________ in __________________ , __________________ , and authorized __________________ to pay medical claims of qualified employees of __________________ from that account. __________________ is not affiliated with __________________ as a parent or subsidiary corporation, but is wholly independent of __________________ . 8. Pursuant to said Shared Fund Agreement, __________________ deposited certain sums into said bank account to cover a portion of possible claims for medical benefits and an additional amount called "retention" which was designed to cover __________________ 's administrative expenses such as premium taxes and overhead to process claims. 9. At the end of each policy year ( ____________ ), __________________ computed an experience report pursuant to said Agreement in order to determine the amount of claims funded by __________________ and the amount of claims funded by __________________ . This experience report involved comparing the total amount of claims paid, the maximum claim liability of __________________ , the amount of paid claims funded by __________________ , and the amount of paid claims funded by __________________ . Should the amount funded by __________________ exceed the amount funded by __________________ , an amount called "unused liability" would be due and payable to __________________ from __________________ . 10. Effective ____________ , _____ , __________________ terminated said Shared Fund Agreement with regard to medical coverage while continuing certain group life insurance coverage with __________________ . In accordance with said Shared Fund Agreement, __________________ owes __________________ the following sums: $ ____________ -- unused liability for the policy year ending ____________ ____________ -- unused liability for "short" policy year ending ____________ ____________ -- processing fee (i.e., retention) $ ____________ -- total due 11. That pursuant to invoices and various correspondence from __________________ to __________________ , __________________ has repeatedly requested and demanded payment of said amount due of __________________________ ($ ____________ ), but __________________ has repeatedly refused to pay same. 12. Defendant __________________ owes Plaintiff, __________________ , the amount of __________________________ ($ ____________ ) plus legal interest from ____________ , _____ , in the amount allowed by applicable law. WHEREFORE, Plaintiff demands Judgment in the amount of __________________________ ($ ____________ ), plus interest at the legal rate from ____________ , _____ , until paid; Plaintiff further demands costs and attorneys' fees as allowed by law, together with such additional relief to which Plaintiff is equitably entitled. Respectfully submitted, __________________ By: ________________________________________ __________________ By: ________________________________________ __________________ Attorneys for __________________ __________________ __________________ OF COUNSEL FOR PLAINTIFF: __________________ __________________ __________________ Telephone No. __________________