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SU6002 ~
NOTICE OF LIEN
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FOR PAYMENT OF
COMPENSATION AND MEDICAL BENEFITS ~
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COMES NOW UNDERWRITERS ADJUSTING COMPANY, a workers'
compensation carrier for the employer of JACKIE J. MALINOWSKI, ~
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and pursuant to Chapter 440.39(a), of the Florida Statutes, ~
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hereby gives notice that the employee, JACKIE J. MALINOWSKI,
was in the scope and course of her employment with the employer,
GLADIEUX CORPORATION, SUNSHINE RESTARAUNT, when she was inured
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and UNDERWRITERS ADJUSTING COMPANY has paid to the employee,
the total sum of $.2,614.28 for workers' compensation and
medical benefits and is continuing to pay these benefits.
WHEREFORE, UNDERWRITERS ADJUSTING COMPANY, claims a
lien upon any recovery by the claimant for the full amount of
benefits previously paid to the employee under the Florida
Workers' Compensation Act in any claim against any third party +
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as a result of said accident.
I HEREBY CERTIFY that a true and correct copy of the
foregoing has been furnished by mail to Paul Gamba, Esquire,
P. O. Box 1016, Stuart, FL 33494, this 3rd day of Novei!zber, ~
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j 1980.
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WZ ESS B. C. PYL , E IRE - O
Whittaker, Py e, Stur.~p & Webste~
Post Office Box 6126-C
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~ 1 ~ Orlando, FL 32803 ~
WITNESS 305/425-2583
Counsel for UNDERWRITERS
ADJUSTING COMPANY.
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STATE OF FLORIDA)
COUNTY OF ORANGE)
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BEFORE ME, the undersigned officer duly authorized to i
administer oaths and take acknowledgments, this day personally
appeared, B. C. PYLE, who, being first duly sworn, deposes and
~ .says that he has read the foregoing, that the facts and matters
$ are true and correct, and that he has executed same for the
purposes expressed therein. "
!!~a~,;•<._ WITNESS my hand and official seal, this o~~ • day
~ ~ • 1980. FILED AWD REC~SOEO
f ~'s:~",''x~ ~'~s a~'~.~V~~ ST.LUC'F'f«" -.FLA. ~
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C-STATE OF FLORIDA
' ` ;8ion Expires : This instrument prepared by
'%r,~i~iR'tr PuBlrc, sT~-~ o~ B. C. Pyle, P. O. Box 6126-C,
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` ' ' ~ ~ T'"""` Orlando, FL 32803 I ~
MY CbRAPAISSI;;t~ EXr;R~;, ~.;i_,.;.;~f, i3, 1~;>2 305/425-2583 ~
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