DCPI           / 2024 

IN THE COURT COURT OF THE

JURISDICTION_STATE

PERSONAL INJURIES ACTION NO.       OF 2024

____________________

BETWEEN

                                                PLAINTIFF_NAME                               Plaintiff

and

                                               DEFENDANT_NAME                         Defendant

                                                  ____________________

 
 NOTICE TO INSURER

                TAKE NOTICE that the abovenamed Plaintiff has on WRIT_DATE commenced this action in the District Court against the Defendant for damages for personal injuries caused to the Plaintiff by reason of negligence and/breach of statutory duties and/or breach of implied terms of the employment contract and/or breach of employer's duty of care owed to the Plaintiff and/or breach of common duty of care under the Occupiers Liability Ordinance, Cap. 314 on the part of the Defendant and/or its employees and/or servants and/or agents in an accident which took place on ACCIDENT_DATE at ACCIDENT_LOCATION. The Defendant was the employer of the Plaintiff at the material time.

........................................