Fill and Sign the Auto Accident 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 [ INSERT CAPTION ] COMPLAINT (SIMPLE NEGLIGENCE-AUTOMOBILE-DRIVER VS. DRIVER) COMES NOW the Plaintiff, [ insert name of plaintiff ], by counsel, and for his (or her) Complaint against the Defendant, [ insert name of defendant ], alleges and states: PARTIES 1. The Plaintiff, [ insert name of plaintiff ], (hereinafter referred to as the Plaintiff), at all times relevant hereto, is/are adult citizens of the State of [ insert state jurisdiction] and reside in [ insert county name ], 2. The Defendant, [ insert name of defendant ], (hereinafter referred to as Defendant), is an adult citizen of [ insert name of county ] County, State of [ insert state jurisdiction ], and is last known to reside at: [ insert defendant’s address, city and zip code ]. FACTS 3. On or about [ insert date ] the Plaintiff was operating his [ insert description of vehicle ] automobile on [ insert name of roadway, direction of travel and the nearest intersection or traffic control device or other landmark ], with the road and weather conditions being: [ insert road and weather conditions at time of accident ]. At said time and place the roadway was 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. ]. 4. At said time and place, the Defendant 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 ]. At said time and place, the Defendant: [ 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. ]. - 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 5. At said time and place, Defendant’s automobile collided with Plaintiff’s automobile 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 disability; lost wages, lost or diminished earning capacity, past, present & future medical bills and expenses; property damage, etc.]. CLAIMS 6. The Defendant had a duty to: [ insert traffic statutes, rules, regulations, & ordinances ]. 7. The Defendant 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 8. The Plaintiff prays for the following relief: (1) Trial by jury; (2) Judgment for Plaintiff and against Defendant; (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; property damage, etc. ]. (4) Such other and further relief deemed just and proper in the premises. - 2 -