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I)I'I ICLR
JEFF ATtVATER
snAI Ii oli I I OR) t&A
14-073149
RICHARD KOCOT,
PLA INTIFF(S),
VS,
CASE JJ; 502014CA 007311 XXXXMB
COURT: CIRCUIT COURT
COUNTY: PALM BEACH
DFS-SOP{{1;14-073149
FLORIDA COMBINED LIFE INSURANCE COMPANY
DFFENDANT(S),
CIVIL ACTION SUMMONS, COMPLAINT, EXI-II BITS
NOTICE OF SERVICE OF PROCESS
NOTICE IS HFREIBY GIVEN of acceptance of Service of Process
by
the Chief Financial
Officer of the State of Florida, Said process was received in my
office
by
PROCESS SERVER
on the 23rd day of June, 2014 and a copy
was forwarded
by
Electronic Delivery on the 30th day
of June, 2014 to the designated agent for the named entity as shown below.
FLORIDA COIVIBINED LIFE INSURANCE COMPANY
LYNETTE COLEMAN
CORPORATION SERVICE COM PANY
1201 HAYS STREET
TALLAHASSEE, FL 32301
*
Our office cvill only serve the initial process (Summons and Complaint) or Subpoena and is not responsible for transmittal of any
subsctiuent fiiings, pleadings or documents unless othcmvisc ortlcrcd by the Court pursuant to Florida Rules of Civil procedure, Rulc gl.{)go.
Jeff Atwater
Chief Financial Officer
ec to, Plaintiffs Representative for liling in appropriate court,
MATTHEW T, RAMENDA
505 SOUTH FLAGLER DRIVE,
STE. 1100
WEST PALM BEACH FL 33401
TMB
EXHIBIT
"1"
Dividion of Legal Services - Service ol'Process Section
200 East Gsines Strcct ~ PQ Itov 6200 ~ Tails))asses, Flotlda 323{46200
~ {810)413%200 -
Fax {850)922 2544
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 1 of 43
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CIVIL ACTION SUMMONS("
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THE CIRCUIT COURT OF THE 15TH
iC. JiUDICIAL CIRCUIT IN AND FOR PALM
BEACH COUNTY, FLORIDA
CASE NO. 502014CA007311XXXXlvIB
RICHARD KOCOT,
Plaintiff,
FLORIDA COMBINED LI FE
INSURANCE, INC.
Deferrdant(s).
Tlm8'y:
THE STATE OF FLORIDA:
To All and Singular the Sheriffs of the State:
YOU ARE COMMANDED to sei ve this Summons aiid a copy
of the
Complaint
in this action orr
Defendant:
Name of corporation
13y serving its Registered Agent.
Address:
Florida Combined Life Insur;incc Company,~
Chief Financial Officer
200 E. Gaines Street
Tallahassee, FL 32399-0000
Each Defendant is required to serve written defenses to the Complaint on Plaintiff's attorney, whose name
and address is:
Matthew T. Ranreiida, Esquire
Jones, Foster, Jolinston 0, Stubbs, I'.h.
505 South Flagler Drive, Suite 1100
West Palm Beach, Florida33401-3475
(561) 659-3000
within 20 days after senicc of this Summons on that Defendant, exclusive of the day ol'service, and to
file the original of the defenses with the Clerk of this Court either before service on Plaintiffs attorney or
immediately thereafter. If a Defendant fails to do so, a default will be entered against that Defendant
for'he
relict demanded in the Complaint,
DATED this
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Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 2 of 43
RICHARD KOCOT,
Plaintiff,
IN THE CIRCUIT COURT OF THE
FIFTEENTH JUDICIAL CIRCUIT IN AND
FOR PALM BEACH COUNTY, FLORIDA
CASE NO, 502014CA007311XXXXMB
Fl ORIDA COMBINED LIFE
INSURANCE COMPANY, INC.,
a Florida corporation,
Defendant.
COMPLAINT
COMES NOW Plaintiff Richard Kocot to sue Defendant Florida Combined Life
Insurance Company, Inc., and alleges as follows..
PARTIES
Richard Kocot
("
Mr. Kocot"), a natural person, is the beneficiary of the life
insurance policy issued by
Defendant.
2. Florida Combined Life Insurance
Company,
Inc.
("
Florida Combined Life"
)
is an active Florida corporation with a principal place of business located at the following
street address, 4800 Deerwood Campus Parkway, Building 200, Suite 600,
Jacksonville, FL 32246.
JURISDICTION 8 VENUE
3. This is an action for damages in excess of $15,000.00 exclusive of
interest, attorney's fees and costs
. 4. This Court has jurisdiction of this action pursuant to
g
26.012, Fla. Stat.
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 3 of 43
Kocot v. Florida Combined Life ins. Co,
Case No.
Complaint
Page 2of 5
5. Venue is proper in Palm Beach County, Florida pursuant to
H
47,011 8
47.051, Fla, Stat., in that: (1)
the contract was breached in Palm Beach County,
Florida, and
(2)
the Certificate of Insurance was issued in Palm Beach County,
GENERAL ALLEGATIONS
6. In December of 2010, Dawn Mi. Kocot ("Ms, Kocot") applied for group term
life insurance through her employer, Comprehensive Pain Management.
7. Also in December of 2010, F'iorida Combined Life delivered to Ms, Kocot
in Palm Beach County, Florida, a 19-page document executed by
the President and
Secretary of Florida Combined Life entitled "Certificate for Group Life and Short Term
Disability
Insurance" (the
"Certificate of Insurance," attached hereto as Exhibit 1).
8. The cover page
of the Certificate of Insurance provides the following:
"Policy: We haveissued the group policy lo the policyholder. The policy
is a contract ofinsurance
1. between your policyholder and us; and
2. fhrough which vou are insured."
See Certificate of Insurance, p. 1 (emphasis supplied).
9.
Page'3 of the Certificate of Insurance provides the following specific and
unambiguous
information relating to the insurance coverage Florida Combined Life
provided to Ms. Kocot:
POLICYHOLDER
COMPREHENSIVE PAIN MANAGEIIENT
GROUP POLICY NUMBER 85244003
CERTIFICATE HOLDER
See Certificate of Insurance, p,
3.
DAWN M. KOCOT
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 4 of 43
Kocot v. Florida Combined Life ins. Co.
Case No,
Complaint
Page 3 of 5
10. Page 3 of the Certificate of Insurance further provides that "Effective
02/01/11" the benefit amount on the Insured's term life insurance is
"$
25,000.00."
11, In addition to the information contained on Page 3 of the Certificate of
Insurance which indicates that coverage commenced effective on February 1, 2011, the
"DEFINITIONS" section contained within the Certificate of Insurance provides the
following definition:
"'Effective date' the date the policy is put in force, it is shown on page
three of the certificate."
See Certificate of Insurance, p. 5.
12. The Certificate of Insurance, which indicated that coverage was effective
on February 1, 2011, was the oniy document pertaining to the effective date of
insurance coverage received by Ms, Kocot from Florida Combined Life.
13. Ms. Kocot received no written communication of any kind from Florida
Combined Life, either before or after February 1, 2011, indicating that the insured's term
life insurance would not or did not become effective on February 1, 2011,
14. When Ms. Kocot passed away on January 14, 2013, Ms. Kocot was
covered by the term life insurance provided by Florida Combined Life.
15. On March 6, 2013, the Employee Death Claim Statement (the
"Claim
Statement," attached hereto as Exhibit 2) was properly submitted to Florida Combined
Life.
16. Florida Combined
Lif'e
has refused to
pay
Mr. Kocot the $25,000 death
benefit to which he is entitled.
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 5 of 43
Kocot v Florida Combined Life Ins, Co,
Case No.
Complaint
Page4of5
COUNT I
BREACH OF CONTRACT
17, Mr. Kocot realleges the allegations contained in Paragraphs 1 through 16
and fully incorporates each and every one of those paragraphs into Count I.
18. Mr. Kocot is the beneficiary of a life insurance contract which is'evidenced
by
the Certificate of Service.
19. Pursuant to the terms of the life insurance contract, Mr. Kocot is entitled to
receive $25,000 as the beneficiary.
20, Florida Combined
Lif'e has materially breached the life insurance contract
by failing to pay
Mr. Kocot the $25,000 death benefit to which he, as the beneficiary, is
entitled.
21, Mr. Kocot has been monetarily damaged as a direct result of Florida
Combined
Life's material breach.
WHEREFORE, Mr. Kocot respectfully requests this Court enter judgment in favor
of Mr. Kocot and against Florida Combined Life:
(1)
providing for damages in the
amount of
$
25,000,00, (2)
awarding attorney's fees and costs in favor of Mr. Kocot and
to be paid by
Florida Combined Life pursuant to
g
627.428, Fla. Stat. and
g
57.041, Fla.
Stat,, and
(3)
providing such other and further relief in favor of Mr. Kocot as the Court
deems just and proper.
I
r
h
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 6 of 43
Kocot v. Florida Combined Life Ins. Co,
gase No.
Complaint
Page 5 of 5
DEMAND FOR JURY TRIAL
Plaintiff demands a trial by jury on all claims and issues so triable,
Dated this 16th day of June, 2014.
JONES, FOSTER, JOHNSTON 5 STUBBS, P,A.
Counsel for l lainfiff
505 South Flagler Drive, Suite 1100
West Palm Beach, Florida 33401
Telephone: (561)
659-3000
+Elec Ionic
Mail:
mragmen
a~ja
eeioeier.corn
r
., jnW
Fla. Bar No, 863076
Case 9:14-cv-80945-KAM Document 1-1 Entered on FLSD Docket 07/16/2014 Page 7 of 43
F(orlda Cosnbined Lite Insurance Company, Inc, ATTN; Group Claims Dopa&trner&t
P.O. EIox 45132
10 receive claims assistance, please
Jacksonv(l(e, Florida
32232-61'32 cz&(i 1-800-696-()552,
EMPLOYEE DEATH CLAIM STATEMEh)T
If you are making claim for a deceased INSURED DEPENDENT,
complete
Page 2 only.
BENEFiCIARY REPORT OF CLAIM
1. Fait legalneme O1deoeaeed emPIOyee;
'2.
DateOfblith t&E&fL/Oy/Yr): )3. D~te OfdePth(&/&cp/Day/Yr);
)4
EmPIOyee SCClal ~S'umber;
Dj&r
tern VV//7 vyd/0.
~f/" I +-( Y-~op
5. Causa of employee's death; 5, VVneh O&O ceoeaaed emplOyee'S hea(lh grat be00ma (7, VVffcrr uru
.d emplOyea flret
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