IN THE SUPREME COURT OF BELIZE A.D.

2015
CLAIM NO

of 2015
BETWEEN
JORGE JIMENEZ

CLAIMANT

AND
NATIONAL AGGREGATES LTD.

DEFENDANT

CLAIM FORM
The claimant,

Jorge Jimenez of 21 miles Rockville, George Price Highway

claims against
the defendant,

National Aggregates Ltd., 1 miles George Price Highway

1.

That on February 16, 2015 at approximately 3:30pm, claimant was at National Aggregates
Ltd. where he was employed as store room clerk.

2.

That while lifting an inspection door of a Tesab Impact Crusher on abovementioned date,
the door somehow slipped and crushed claimants right index finger.

3.
.