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IN THS CIRCUIT COURT OF THE ti
NINETEENTH JUDICIAL CIRCUIT l;
_ IN AND FOR ST. LUCIE COUNTY,
FLORIDA
- _ i°
• CASE NO. ?9 333 CA
HARRY HANSEL PICRLESIMER )
and ELOISE R. PICRLESIMER, ) -
his wife, ) NOTICE OF PAYMENT
) OF
Plaintiffs, ) WORKER'S COMPENSATION-
) - AND _ -
~ vs. ) MEDICAL BENEFITS
AND _
LEE BROCR and PHILIP M. BAKER ) ` CLAIM OF LIEN THEREFOR
and OHIO CASUALTY COMPAisTY, ) - ,
Defendants. ) r
- )
PENINSULAR LIFE INSURAI~ICE COMPANY, employer, and COMMERCIAL _
UNION ASSURANCE COMPANIES, workers' compensation carrier for the
,said employer of HARRY HANSEL PICKLESIMER, plaintiff in the above-
styled cause, by and through their undersigned attorney and-pursuant
to Section 440.33(3), Florida Statutes, file their notice of payment
of compensation and medical benefits paid and/or_to be paid to or on
behalf of the said employee and/or plaintiff.
WHEREFORE, PENINSULAR LIFE INSURANCE COMPANY and COMMERCIAL
UNION ASSURANCE COMPANIES hereby affirm-and assert their lien upon
any judgment or settlement recovered by the above-named plaintiffs
against the above-named defendants to the extent that the Court may
determine as their pro rata share of said judgment or settlement for
compensation and medical benefits paid and/or to be paid under the
provisions of Chapter 440-:, Florida Statutes. -
I HEREBY CERTIFY that a copy of the foregoing has been mailed 1
this 19th day of September, 1979 to C.R. McDonald, Esquire, attorney
for Plaintiffs and Ohio Casualty Company, insurance carrier for
Defendants.
~~S Y D. ROBI ON -
2247 Palm Beach Lakes Blvd.
1979 SAP ?4 P!~ ~ 31 West Palm Beach, Florida 33409
Ft~EO ~d~ r~cuK~«u Attorney for Employer/Carrier
ST. LliC1E COiiNT Y. f l% .
ROGER PoITRas
CLERK CIRCIfIT Cott
RECORO VERtFtEt`
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