Fill and Sign the Accident Guest Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT (NEGLIGENCE-AUTOMOBILE-GUEST PASSENGER VS. BOTH DRIVERS) COMES NOW the Plaintiff, [ insert name of plaintiff ], by counsel, and for his (or her) Complaint against the Defendants, [ insert name of defendant s], alleges and states PARTIES 1. The Plaintiff, [ insert name of plaintiff ], (hereinafter referred to as the Plaintiff), at all times relevant hereto, is an adult citizen of the State of [ insert state jurisdiction] and resides in [ insert county name ]. 2. The Defendant, [ insert name of driver #1 ], (hereinafter referred to as “Defendant"), at all times relevant hereto, is an adult citizen of the State of [ insert state jurisdiction] and resides in [ insert county name ]. 3. The Defendant, [ insert name of driver #2 ], (hereinafter referred to as Defendant #2"), at all times relevant hereto, is an adult citizen of the State of [ insert state jurisdiction] and resides in [ insert county name ]. - 1 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 FACTS 4. On or about [ insert date ] the Plaintiff was a guest passenger in an [ insert description of vehicle ] automobile being operated by Defendant #1 on [ insert name of roadway, direction of travel and the nearest intersection or traffic control device or other landmark ], which said roadway is a: [ insert description of roadway and traffic control, e.g., 2 or 4 lane roadway, north and south directions, stop lights or stop signs, etc. ]. At said time and place, the road and weather conditions were: [ insert road and weather conditions at time of accident ]. 5. At said time and place, Defendant #2 was operating a [ insert description of vehicle ] automobile on insert name of roadway, direction of travel and the nearest intersection or traffic control device or other landmark ], which said roadway is a: [ insert description of roadway and traffic control, e.g., 2 or 4 lane roadway, north and south directions, stop lights or stop signs, etc. ]. 6. At said time and place, Defendant # 1 operated his automobile in a negligent and careless manner by: [ insert description of violation of traffic laws, rules, regulations, rules of the road, etc., e.g., failure to yield right-of-way, failure to keep a proper look out, speeding, failure to keep vehicle under proper control, intoxication, etc. ]. 7. At said time and place, Defendant # 2 operated his automobile in a negligent and careless manner by: [ insert description of violation of traffic laws, rules, regulations, rules of the road, etc., e.g., failure to yield right-of-way, failure to keep a proper look out, speeding, failure to keep vehicle under proper control, intoxication, etc. ]. 8. At said time and place, the automobiles being operated by Defendant #1 and Defendant #2 collided causing the Plaintiff to sustain: [ insert the types of damages, e.g., severe & permanent personal injuries; past, present & future pain & suffering; past, present & future mental anguish; loss of enjoyment of life’s activities; permanent or temporary partial/total - 2 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 disability; lost wages, lost or diminished earning capacity, past, present & future medical bills and expenses; etc . ] . CLAIMS 9. The Defendants, and each of them, had a duty to: [insert traffic statutes, rules, regulations, & ordinances] . 10. The Defendants, and each of them, breached the duties delineated hereinabove proximately causing or proximately contributing to the cause of the collision and Plaintiff’s damages alleged herein. DEMAND FOR RELIEF 11. The Plaintiff prays for the following relief: (1) Trial by jury; (2) Judgment for Plaintiff and against Defendants, jointly and severally; (3) An award of damages which will fully and fairly compensate Plaintiff for [ insert the types of damages, e.g., severe & permanent personal injuries; past, present & future pain & suffering; past, present & future mental anguish; loss of enjoyment of life’s activities; permanent or temporary partial/total disability; lost wages, lost or diminished earning capacity, past, present & future medical bills and expenses; etc.]. (4) Such other and further relief deemed just and proper in the premises. Respectfully submitted, Dated: Name:       Title:       - 3 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Address:       Address:       City, State, Zip:       Phone:       Fax:       E-Mail:       Attorney No.:       CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. _________________________________ - 4 -