Statement Of Claim Auto Collision With Medical Expenses
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Statement Of Claim Auto Collision With Medical Expenses Form. This is a Florida form and can be use in Orange Local County.
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Tags: Statement Of Claim Auto Collision With Medical Expenses, Florida Local County, Orange
IN THE COUNTY COURT OF THE
NINTH JUDICIAL CIRCUIT OF FLORIDA
ORANGE COUNTY, FLORIDA
Case Number ____________________
Plaintiff(s)
VS
Defendant(s)
STATEMENT OF CLAIM
AUTO COLLISION WITH MEDICAL EXPENSES
The above named Plaintiff(s) sue(s) the above named Defendant(s) for :
1. That
on
or
about
__________________________________,
at:
_____________________________________________________________________
City, ____________________, County, ________________, State, ______________
the defendant ____________________________________ willfully and/or recklessly
and/or negligently drove a motor vehicle owned by ___________________________
against the motor vehicle of the plaintiff(s) thereby damaging the same, depreciating
its market value, and causing plaintiff(s) to lose the value of its use during its repair.
2. Because of the facts stated in paragraph one (1) hereof, plaintiff(s)
_______________________________________________ suffered painful bodily
injuries requiring hospitalization and or medical treatment, for the reasonable cost of
which plaintiff(s) became obligated to pay.
And Plaintiff(s) claim(s) $
interest, court costs and attorney fees.
damages not to exceed $5,000.00 exclusive of
______________________________
Plaintiff(s)
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