Document for Wayne Henry Plaintiff vs. American Security Insurance Company Defendant

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                                Case Number: CACE-21-003829 Division: 08
Filing # 121949019 E-Filed 02/23/2021 09:59:24 PM

FORM 1.997. CIVIL COVER SHEET

The civil cover sheet and the information contained in it neither replace nor supplement the filing
and service of pleadings or other documents as required by law. This form must be filed by the
plaintiff or petitioner with the Clerk of Court for the purpose of reporting uniform data pursuant
to section 25.075, Florida Statutes. (See instructions for completion.)

 

I. CASE STYLE

IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT,
IN AND FOR BROWARD COUNTY, FLORIDA

Wayne Henry
Plaintiff Case #

Judge

VS.

American Security Insurance Company
Defendant

 

I. AMOUNT OF CLAIM
Please indicate the estimated amount of the claim, rounded to the nearest dollar. The estimated amount of
the claim is requested for data collection and clerical processing purposes only. The amount of the claim
shall not be used for any other purpose.

OC $8,000 or less

11 $8,001 - $30,000
U1 $30,001- $50,000
$50,001- $75,000
0 $75,001 - $100,000
O over $100,000.00

Til. TYPEOFCASE _ (ifthe case fits more than one type of case, select the most
definitive category.) If the most descriptive label is a subcategory (is indented under a broader
category), place an x on both the main category and subcategory lines.

re

*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 02/23/2021 09:59:20 PM.****CIRCUIT CIVIL

O Condominium
O Contracts and indebtedness
C Eminent domain
CO Auto negligence
O Negligence—other
C Business governance
C Business torts
0 Environmental/Toxic tort
O Third party indemnification
O Construction defect
OC Mass tort
O Negligent security
OD Nursing home negligence
O Premises liability—commercial
OD Premises liability—residential
O Products liability
CO Real Property/Mortgage foreclosure
0 Commercial foreclosure
C Homestead residential foreclosure
C Non-homestead residential foreclosure
O Other real property actions

OProfessional malpractice
O Malpractice—business
CO Malpractice—medical
D Malpractice—other professional
Other
OD Antitrust/Trade regulation
C Business transactions
OD Constitutional challenge—statute or ordinance
O Constitutional challenge—proposed amendment
OD Corporate trusts
O Discrimination—employment or other
® Insurance claims
C Intellectual property
O Libel/Slander
O Shareholder derivative action
0 Securities litigation
O Trade secrets
O Trust litigation

COUNTY CIVIL

O Small Claims up to $8,000
O Civil
CO Real property/Mortgage foreclosureO Replevins
O Evictions

O Residential Evictions

O Non-residential Evictions
O Other civil (non-monetary)

COMPLEX BUSINESS COURT

This action is appropriate for assignment to Complex Business Court as delineated and mandated by the
Administrative Order. Yes 0 No &

IV. REMEDIES SOUGHT (check all that apply):
Monetary;

O Nonmonetary declaratory or injunctive relief;

O Punitive

V. | NUMBER OF CAUSES OF ACTION: [ ]
(Specify)

1

VI. IS THIS CASE A CLASS ACTION LAWSUIT?
O yes
no

VII. HAS NOTICE OF ANY KNOWN RELATED CASE BEEN FILED?
no
O yes If “yes,” list all related cases by name, case number, and court.

VILL. IS JURY TRIAL DEMANDED IN COMPLAINT?
& yes
Ono

ICERTIFY that the information I have provided in this cover sheet is accurate to the best of
my knowledge and belief, and that I have read and will comply with the requirements of
Florida Rule of Judicial Administration 2.425.

Signature: s/ E. Terrell Matthews Fla. Bar # 89564
Attorney or party (Bar # if attorney)
E. Terrell Matthews 02/23/2021
(type or print name) Date