AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

SYCAMORE SPRINGS SURGERY CENTER, L.L.C.

C/O CARYN FINK, REGISTERED AGENT

4715 STATESMEN DR STE A

INDIANAPOLIS, IN 46250

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 1 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 2 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

SURGICAL CENTER DEVELOPMENT #3 LLC

C/O NEVADA BUSINESS SERVICES, REGISTERED AGENT

1805 N CARSON STREET SUITE X

CARSON CITY, NV 89701

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 3 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 4 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

RIVERVIEW SURGERY CENTER LLC

C/O RITA RAMSEY, REGISTERED AGENT

1276 NORTH PLAZA DRIVE SUITE 100

ROCKPORT, IN 47653

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 5 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 6 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

MUNSTER SPECIALTY SURGERY CENTER LLC

C/O GREGORY FOX MD, REGISTERED AGENT

639 S. WALKER STREET, SUITE E

BLOOMINGTON, IN 47403

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 7 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 8 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

METRO SPECIALTY SURGERY CENTER, L.L.C.

C/O LEE ANN MASSEY, REGISTERED AGENT

200 MISSOURI AVE BLDG 18 STE A

JEFFERSONVILLE, IN 47130

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 9 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 10 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

SURGICAL CENTER DEVELOPMENT, INC.

C/O NEVADA BUSINESS SERVICES, REGISTERED AGENT

1805 N CARSON STREET SUITE X

CARSON CITY, NV 89701

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 11 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 12 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

SOUTH BEND SPECIALTY SURGERY CENTER LLC

C/O RALPH LANTZ, REGISTERED AGENT

335 FLORENCE AVENUE, SUITE 1B

GRANGER, IN 46530

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 13 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 14 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

NORTHWEST REGIONAL SURGERY CENTER LLC

C/O STEPHANIE MCLAIN, REGISTERED AGENT

8900 BROADWAY AVENUE, SUITE 100W

MERRILLVILLE, IN 46410

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 15 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 16 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

MIDWEST SPECIALTY SURGERY CENTER LLC

C/O GREGORY FOX MD, REGISTERED AGENT

639 S. WALKER STREET, SUITE E

BLOOMINGTON, IN 47403

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 17 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 18 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

INDIANA SPECIALTY SURGERY CENTER, LLC

C/O LINDA GIEDROC, REGISTERED AGENT

1380 W ARCH HAVEN AVE

BLOOMINGTON, IN 47403

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 19 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 20 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

COLUMBUS SPECIALTY SURGERY CENTER LLC

C/O JOY TURNER, REGISTERED AGENT

2425 NORTHPARK DRIVE, SUITE 20

COLUMBUS, IN 47203

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 21 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 22 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

ADVANCED REGIONAL SURGERY CENTER LLC

C/O GREGORY FOX MD, REGISTERED AGENT

3630 E COMMODORE TRAIL

BLOOMINGTON, IN 47408

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 23 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 24 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT

for the

__________ District of __________ 

)

)

)

)

)

)

)

)

)

)

)

)

Plaintiff(s)

v. Civil Action No.

Defendant(s)

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you

are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.

P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of

the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,

whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint. 

You also must file your answer or motion with the court.

CLERK OF COURT

Date:

Signature of Clerk or Deputy Clerk

Northern District of Indiana

CONNECTICUT GENERAL LIFE INSURANCE

COMPANY, CIGNA HEALTH AND LIFE

INSURANCE COMPANY

2:15-cv-00253

NORTHWEST REGIONAL SURGERY CENTER

LLC, ET AL.

CARMEL SPECIALTY SURGERY CENTER LLC

C/O TRACY GOODIN, REGISTERED AGENT

11590 N. MERIDIAN ST. STE 130

CARMEL, IN 46032

Daniel K. Ryan

Hinshaw & Culbertson LLP

222 North LaSalle Street

Suite 300

Chicago, IL 60601-1081

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 25 of 26
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on (date) .

u I personally served the summons on the individual at (place)

on (date) ; or

u I left the summons at the individual’s residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individual’s last known address; or

u I served the summons on (name of individual) , who is

 designated by law to accept service of process on behalf of (name of organization)

on (date) ; or

u I returned the summons unexecuted because ; or

u Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:

Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:

2:15-cv-00253

0.00

USDC IN/ND case 2:15-cv-00253-JD-PRC document 4 filed 07/07/15 page 26 of 26