Miscellaneous: ANN PEARSON vs STATE FARM FLORIDA INSURANCE COMPANY

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                                16-2022-CA-005378-XXXX-MA Div: CV-D

    Filing # 157047730 E-Filed 09/08/2022 11:57:49 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/COUNTY COURT OF THE FOURTH JUDICIAL CIRCUIT,
                                      IN AND FOR DUVAL COUNTY, FLORIDA

            ANN PEARSON,           SAM PEARSON
            Plaintiff                                                                  Case #
                                                                                       Judge
            Vs.
            STATE FARM FLORIDA 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.

             1    $8,000 or less
            O $8,001 -      $30,000
              $30,001-       $50,000
            © $50,001-       $75,000
            0 $75,001      - $100,000
             O over $100,000.00

                     Til.   TYPE OF CASE            (If the 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.




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ACCEPTED: DUVAL COUNTY, JODY PHILLIPS, CLERK, 09/16/2022 12:50:55 PM
CIRCUIT CIVIL

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

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

COUNTY CIVIL

O Small Claims up to $8,000
O Civil
O Real property/Mortgage foreclosure
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O 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 1 No

         Iv.        REMEDIES SOUGHT (check all that apply):
         & Monetary;
         0 Nonmonetary declaratory or injunctive relief;
         O Punitive

         Vv.        NUMBER OF CAUSES OF ACTION: [ ]
         (Specify)
               i1

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

         Vil.       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


         IX.        DOES THIS CASE INVOLVE ALLEGATIONS OF SEXUAL ABUSE?
                    O yes
                    & no


 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/ Kevin Weisser                              Fla. Bar # 98828
                 Attorney or party                                        (Bar # if attorney)

Kevin Weisser                              09/16/2022
 (type or print name)                              Date

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