Fill and Sign the Motion to Intervene Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) MOTION FOR LEAVE TO INTERVENE AND FILE INTERVENOR'S COMPLAINT _______________, moves this Court for an Order granting it leave to intervene in the above styled and numbered cause pursuant to Rule ______ of the ____________ Rules of Civil Procedure, and would respectfully show the Court the following; 1. Plaintiff _______________ herein has alleged that Defendant negligently operated a motor vehicle and that as a result Plaintiff _______________ has incurred damages. 2. Pursuant to a contract issued by _______________ which provides hospital and health/medical benefits for the Plaintiff _______________, or on his behalf (Contract No. ___), Petitioner herein has paid, to date, $__________ in benefits on behalf of the Plaintiff _______________ under said contract. 3. Pursuant to the terms of the contract under which said payments have been made , _______________ has a right of subrogation and is entitled to repayment of all amounts paid by it to or on behalf of Plaintiff _______________. - 2 - WHEREFORE, PREMISES CONSIDERED, _______________ respectfully moves this Court for leave to intervene in this cause as a Party-Plaintiff, and it be al lowed to file its Intervenor's Complaint, a true copy of which is attached hereto as Exhibit "A", for the prot ection of its rights under the contract referred to hereinabove. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: 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____.