§ Form 17 Complaint on Insurance Policy

Codes > Wyoming Rules of Civil Procedure > Appendix of > Form 17

Form 17. Complaint on Insurance Policy

    1. (Here set out the grounds upon which the court's jurisdiction depends.)

    2. On or about June 1, 1955, defendant, for a valuable consideration, issued to G. H. a policy of life insurance whereby defendant promised to pay to plaintiff as beneficiary the sum of ten thousand dollars ($10,000.00) upon the death of G. H.

    3. On September 1, 1976, G. H. died.

    4. All conditions precedent to liability under said policy have been performed or have occurred.

    5. Defendant has not paid plaintiff the sum of ten thousand dollars ($10,000.00) or any part thereof.

    Wherefore plaintiff demands judgment against defendant for the sum of ten thousand dollars ($10,000.00), interest, and costs.