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Appendix I: Sample Court Document (One Page Complaint)

JOE JOHNSON * IN THE DISTRICT COURT
1234 Valley Drive * OF MARYLAND

Belle Note, Maryland 21101, * FOR NORTH EDWARD
Plaintiff, * COUNTY
v. * CASE NO.: 0000-0000000-2008

STATE INSURANCE FUND. *
Served on: *
Susan Jones. *

Insurance Commissioner *
36 Capitol Place *
Baltimore, MD 21201 *

Defendants.
*****************************************************************

COMPLAINT

Plaintiff, Joe Johnson (hereinafter referred to as the plaintiff), by and through her attorneys Jimmy Smith
and Miller & Smith, LLC, brings suit against the defendant, State Insurance Fund (SIF), and in support
thereof states as follows:

COUNT I – BREACH OF CONTRACT – PIP BENEFITS

1. That at all times, the defendant, SIF, was a corporation licensed in the state of Maryland to pro-
vide insurance, including, but not limited to, personal injury protection (PIP) coverage.

2. That on or before September 7, 20XX, the defendant, SIF, provided a policy of insurance, which
included PIP coverage to the plaintiff.

3. That since January 10, 20XX, the plaintiff has demanded benefits due her under the PIP policy
from the defendant, but the defendant has refused to pay same.

4. That said denial is without justification.

5. That under Maryland Code § 19-508 (c), payment of benefits that are not made within 30 days
after the insurer receives satisfactory proof of claim, said benefits are overdue and shall bear
simple interest at the rate of 1.5% per month.

WHEREFORE, the plaintiff demands judgment against the defendant, SIF, in the amount of
$102,000.00 plus costs.

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