Before the Department of Insurance
State Of Indiana
______________________________________	)
Plaintiff(s)				)
vs.					)
______________________________________	)
______________________________________	)
______________________________________	)


Comes now the Plaintiff(s), _______________________________________, and

for his/her complaint for damages against the Defendant(s), states 

as follows:

     1.  That Plaintiff ____________________, was a patient of the 

Defendant(s), _____________________________________________________________

____________________________________________________, from ________________

through ______________, and received medical care and/or treatment from


     2.  Said medical care or treatment rendered by Defendant(s) was 

negligent and below the appropriate standard of care.

     3.  That as a proximate result of the negligence of the Defendant(s),

the Plaintiff(s) _____________________________, has/have incurred medical

expenses, additional treatment, related expenses, lost wages and/or 

intangible damages of a nature as to require compensation.

WHEREFORE, the Plaintiff(s) respectfully pray(s) for an award against the 

Defendant(s) in an amount that will fairly and fully compensate Plaintiff(s) 

for all losses, injuries and damages, for the costs of this action, and for 

all other just and proper relief.

                                   Respectfully submitted,


Phone: _________________________    Address: _____________________________