On December 29, 2015 a
Motion-Secondary
was filed
involving a dispute between
Tower Imaging Inc,
and
Owners Insurance Company,
for SMALL CLAIMS PIP 1 - UNDER $100
in the District Court of Pinellas County.
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Filing # 40660140 E-Filed 04/25/2016 11:29:32 AM
IN THE COUNTY COURT OF THE SIXTH
JUDICIAL CIRCUIT IN AND FOR
PiINELLAS COUNTY, FLORIDA SMALL
CLAIMS
CASE NO.: 15-011058-SC (South)
TOWER IMAGING, INC., AS ASSIGNEE
OF LAWRENCE POLLIN,
Plaintiff,
Vv.
AUTO-OWNERS INSURANCE
COMPANY,
Defendant.
/
AFFIDAVIT OF JILLIAN NICKLE
STATE OF FLORIDA )
COUNTY OF “Pole }
|, JILLIAN NICKLE, after being duly sworn, depose and say as follows:
1. My name is JILLIAN NICKLE. | am authorized to handle claims for AUTO-
OWNERS INSURANCE COMPANY and its various subsidiaries, and | am over the age
of eighteen. The following statements are based upon my own personal knowledge
and/or knowledge which | have obtained by a review of the original documents
contained in the applicable claims file, Claim Number 203-521-2014 kept by Auto-
Owners in the ordinary course and scope of ifs business.
2. {am the Litigation Specialist assigned to the above-referenced case.
Page 1
COLE, SCOTT & KISSANE, P.A.
4301 WEST BOY SCOUT BOULEVARD - SUITE 400 - TAMPA, FLORIDA 33607 - (813) 269-9300 - (813) 286-2900 FAX
***ELECTRONICALLY FILED 04/25/2016 11:29:32 AM: KEN BURKE, CLERK OF THE CIRCUIT COURT. PINELLAS COUNTY***CASE NO.: 15-011058-SC (South)
3. This claim concerns an automobile accident involving LAWRENCE
POLLIN (the “Claimant”), which occurred on September 29, 2014.
4. Lawrence Pollin is not insured under any applicable authomobile
insurance policy issued by AUTO-OWNERS INSURANCE COMPANY.
5. Rather, OWNERS INSURANCE COMPANY issued an automobile
insurance policy (the “Subject Policy”) to the Claimant, which included $10,000.00 in
personal injury protection benefits (“PIP Benefits”). True and correct copies of the
Declarations of Coverages page and Subject Policy, including all endorsements and
amendments, are attached hereto as Exhibit “A” and Exhibit “B.”
6. The subject policy was incepted on December 7, 2013, and in effect from
December 7, 2013 through December 7, 2014. A true and correct copy of Policy
Number 49-677-886-00, including all endorsements and amendments is attached
hereto as Exhibit “B.”
The above statements are true, accurate and correct.
FURTHER AFFIANT SAYETH NAUGHT.
ILLIAN NICKLE
STATE OF FLORIDA )
. ) Ss
COUNTY OF PO\K )
BEFORE ME personally appeared JILLIAN NICKLE, known to be the person named in the
foregoing instrument who is personally known to me or who has produced as
identification and has acknowledged before me that he executed the foregoing Affidavit
freely and voluntarily for the purposes therein expressed.
Page 2
«FIRM_NAME_LINE_1»
4301 WEST BOY SCOUT BOULEVARD - SUITE 400 - TAMPA, FLORIDA 33607 - (813) 289-9300 - (813) 286-2900 FAXCASE NO.: 15-011058-SC (South)
WITNESS my hand and official seal at said County and State last aforesaid, this
Qa Gay of Macey 2016.
NOTARY PUBLIC, State of
Florida at Large
MY COMMISSION EXPIRES:
ao
ASHLEY RENEE PHILLIPS
Wotary Public - State of Florida
Commission # FF 897726
Comm. Expires Jul 31, 2016
Page 3
«FIRM_NAME_LINE_1»
4301 WEST BOY SCOUT BOULEVARD - SUITE 400 - TAMPA, FLORIDA 33607 - (813) 289-9300 - (613) 266.2800 FAX
Document Filed Date
April 25, 2016
Case Filing Date
December 29, 2015
Category
SMALL CLAIMS PIP 1 - UNDER $100
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Filing # 40660140 E-Filed 04/25/2016 11:29:32 AM IN THE COUNTY COURT OF THE SIXTH JUDICIAL CIRCUIT IN AND FOR PiINELLAS COUNTY, FLORIDA SMALL CLAIMS CASE NO.: 15-011058-SC (South) TOWER IMAGING, INC., AS ASSIGNEE OF LAWRENCE POLLIN, Plaintiff, Vv. AUTO-OWNERS INSURANCE COMPANY, Defendant. / AFFIDAVIT OF JILLIAN NICKLE STATE OF FLORIDA ) COUNTY OF “Pole } |, JILLIAN NICKLE, after being duly sworn, depose and say as follows: 1. My name is JILLIAN NICKLE. | am authorized to handle claims for AUTO- OWNERS INSURANCE COMPANY and its various subsidiaries, and | am over the age of eighteen. The following statements are based upon my own personal knowledge and/or knowledge which | have obtained by a review of the original documents contained in the applicable claims file, Claim Number 203-521-2014 kept by Auto- Owners in the ordinary course and scope of ifs business. 2. {am the Litigation Specialist assigned to the above-referenced case. Page 1 COLE, SCOTT & KISSANE, P.A. 4301 WEST BOY SCOUT BOULEVARD - SUITE 400 - TAMPA, FLORIDA 33607 - (813) 269-9300 - (813) 286-2900 FAX ***ELECTRONICALLY FILED 04/25/2016 11:29:32 AM: KEN BURKE, CLERK OF THE CIRCUIT COURT. PINELLAS COUNTY***CASE NO.: 15-011058-SC (South) 3. This claim concerns an automobile accident involving LAWRENCE POLLIN (the “Claimant”), which occurred on September 29, 2014. 4. Lawrence Pollin is not insured under any applicable authomobile insurance policy issued by AUTO-OWNERS INSURANCE COMPANY. 5. Rather, OWNERS INSURANCE COMPANY issued an automobile insurance policy (the “Subject Policy”) to the Claimant, which included $10,000.00 in personal injury protection benefits (“PIP Benefits”). True and correct copies of the Declarations of Coverages page and Subject Policy, including all endorsements and amendments, are attached hereto as Exhibit “A” and Exhibit “B.” 6. The subject policy was incepted on December 7, 2013, and in effect from December 7, 2013 through December 7, 2014. A true and correct copy of Policy Number 49-677-886-00, including all endorsements and amendments is attached hereto as Exhibit “B.” The above statements are true, accurate and correct. FURTHER AFFIANT SAYETH NAUGHT. ILLIAN NICKLE STATE OF FLORIDA ) . ) Ss COUNTY OF PO\K ) BEFORE ME personally appeared JILLIAN NICKLE, known to be the person named in the foregoing instrument who is personally known to me or who has produced as identification and has acknowledged before me that he executed the foregoing Affidavit freely and voluntarily for the purposes therein expressed. Page 2 «FIRM_NAME_LINE_1» 4301 WEST BOY SCOUT BOULEVARD - SUITE 400 - TAMPA, FLORIDA 33607 - (813) 289-9300 - (813) 286-2900 FAXCASE NO.: 15-011058-SC (South) WITNESS my hand and official seal at said County and State last aforesaid, this Qa Gay of Macey 2016. NOTARY PUBLIC, State of Florida at Large MY COMMISSION EXPIRES: ao ASHLEY RENEE PHILLIPS Wotary Public - State of Florida Commission # FF 897726 Comm. Expires Jul 31, 2016 Page 3 «FIRM_NAME_LINE_1» 4301 WEST BOY SCOUT BOULEVARD - SUITE 400 - TAMPA, FLORIDA 33607 - (813) 289-9300 - (613) 266.2800 FAX