Fill and Sign the Invitee Form

JOHN LAWYER, ESQ. 12 MAIN STREET ANYWHERE, USA ATTORNEY FOR PLAINTIFF JANE DOE, Plaintiff, vs. ABC SUPERMARKETS, INC. and/or 123 SUPERMARKETS doing business as ABC SUPERMARKET, XYZ Corp. (fictitious name) and JANE SMITH, Defendants. SUPERIOR COURT OF NEW JERSEY [insert] COUNTY DOCKET NO. CIVIL ACTION COMPLAINT AND JURY DEMAND Jane Doe, residing at [insert address] complaining of the defendants alleges and says: FIRST COUNT 1. At all time relevant hereto the defendant, ABC Supermarkets, Inc. and/or 123 Supermarkets, is a corporation licensed to do business in the State of [insert], owning and operating a supermarket located on [insert address], doing business as ABC Supermarket. XYZ, Inc. (Fictitious names) is named in the event that the proper name for the corporation so owning and operating the Shoprite Supermarket located on [insert address], is other than ABC Supermarket, Inc. and/or 123 Supermarkets (ABC Supermarkets and/or 123 Supermarkets and XYZ, Inc. are, hereinafter, jointly and severely referred to as ABC). 2. At all times relevant hereto, the defendant, Jane Smith ( A Ms. Smith @ ), was a resident of the [insert address]; and was an individual known by ABC to frequent the ABC Supermarket on [insert address] and to be assaultive, combative and aggressive to other patrons, with a history of same being known by ABC. 3. On or about the [insert date] the plaintiff, Jane Doe ( A Mrs. Doe @ ), was a business invitee and was lawfully on the premises of the ABC Supermarket. 4. At the aforesaid time and place, Ms. Smith, did intentionally, wantonly and/or recklessly inflict injury upon Mrs. Doe. 5. ABC failed to exercise due diligence and circumspection in the operation of their business premises, and thereby failed to provide its patrons, including Mrs. Doe, with a business premises in which they could engage in commerce with ABC which premises was free from hazards and/or threats to their safety; which were known or should have been known to ABC Supermarket. 6. As a result of the aforesaid actions or omissions of the defendants, Mrs. Doe, was caused to suffer severe bodily injuries, some of which are permanent in nature; has been caused and will be caused in the future to expend large and diverse sums of money for medical treatment necessary to effect a cure for her injuries; has been caused and will in the future be caused great pain and suffering; and has been caused and will be in the future to be unable pursue her usual and lawful affairs, activities and duties. WHEREFORE, the plaintiff, Jane Doe, demands judgments against the defendants, ABC Supermarkets and/or 123 Supermarkets, XYZ, Inc. (fictitious name) and Jane Smith, jointly, severely, jointly and severely, or in the alternative, for damages, both compensatory and punitive, together with interest, costs of suit, attorneys fees and such other relief as the court may deem equitable and just. SECOND COUNT 1. Plaintiff repeats the allegations of the First Count and incorporates them herein as set forth as length. 2. The aforesaid injuries to Mrs. Doe were caused by the carelessness, recklessness and negligence of ABC Supermarkets, in failing to take proper precautions in making their premises safe for their business patrons, and failing to adequately train and supervise their agents, servants, and/or employees, and otherwise failing to exercise due care under the attendant circumstances. WHEREFORE, the plaintiff, Jane Doe, demands judgment for damages against the defendants, ABC Supermarket, Inc. and/or 123 Supermarket and XYZ, Inc. (fictitious names), jointly, severely, jointly and severely, or in the alternative, for damages, together with interest, costs of suit, attorneys fees and such other relief as the court may deem equitable and just. THIRD COUNT 1. Plaintiff repeats the allegations of the First and Second Count and incorporates them herein as set forth as length. 2. At all times relevant hereto, ABC warranted and represented that the premises operated on [insert address], would be suitable, safe and habitable for the lawful uses of Mrs. Doe. 3. ABC breached the aforesaid warranties and representations; as a result of ABC = s breach of these warranties and representations, Mrs. Doe was caused to sustain serious, painful and permanent injuries; was deprived and will in the future be deprived of attending to her lawful affairs, duties and occupations; and was forced to expend and will in the future be forced to expend diverse sums for medical expenses in an effort to effect a cure for here injuries. WHEREFORE, the plaintiff, Jane Doe, demands judgment for damages against the defendants, ABC Supermarket, Inc. and/or 123 Supermarket and XYZ, Inc. (fictitious names), jointly, severely, jointly and severely, or in the alternative, for damages, both compensatory and punitive, together with interest, cost of suit, attorneys fees and such other relief as the court may deem equitable and just. JURY DEMAND Plaintiff hereby demands a trial by jury of six. 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. ___________________________ JOHN LAWYER