Miscellaneous: ADVANCED MEDICAL ASSOCIATES A/A/O JOSE DERAS vs INFINITY INDEMNITY INSURANCE COMPANY

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                                16-2020-SC-026036-XXXX-MA Div: CC-O

Filing # 117494444 E-Filed 12/02/2020 09:34:37 AM

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 FOURTH JUDICIAL CIRCUIT,
IN AND FOR DUVAL COUNTY, FLORIDA

ADVANCED MEDICAL ASSOCIATES a/a/o Jose Deras

Plaintiff Case #
Judge
vs.
INFINITY INDEMNITY INSURANCE COMPANY
Defendant

Il. 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.

$8,000 or less

CO $8,001 - $30,000
0 $30,001- $50,000
© $50,001- $75,000
0 $75,001 - $100,000
O over $100,000.00

I. 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.

ACCEPTED: DUVAL COUNTY, RONNIE FUSSELL, CLERK, 12/03/2020 02:02:18 PMCIRCUIT CIVIL

O Condominium
CO Contracts and indebtedness
O Eminent domain
CO Auto negligence
CO Negligence—other
CO Business governance
CO Business torts
CO Environmental/Toxic tort
O Third party indemnification
CO Construction defect
C Mass tort
CO Negligent security
C 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
0 Malpractice—business
O Malpractice—medical
O Malpractice—other professional
0 Other
C Antitrust/Trade regulation
CO 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
CO Libel/Slander
CO Shareholder derivative action
O Securities litigation
CO Trade secrets
O Trust litigation

COUNTY CIVIL

& Small Claims up to $8,000
O Civil
O 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 Xi

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

O Nonmonetary declaratory or injunctive relief;

O Punitive

Vv. 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.
0

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

I CERTIFY 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/ Gregory E Gudin Fla. Bar # 14347
Attorney or party (Bar # if attorney)

Gregory E Gudin 12/02/2020
(type or print name) Date