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Fill and Sign the Civilcase Information Statement

Fill and Sign the Civilcase Information Statement

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Revised 09/01/2009, CN 10517_ps-English Page 1 of 2 FOR USE BY CLERK'S OFFICE ONLY PAYMENT TYPE: CK CG CACHG / CK NO.AMOUNT:OVERPAYMENT: CIVILCASE INFORMATION STATEMENT (CIS) Use for initial Law Division Civil Part pleadings (not motions) under Rule 4:5-1 Pleading will be rejected for filing, under Rule 1:5-6(c), if information above the black bar is not completed orif attorney's signature is not affixed. BATCHNUMBER:1. ATTORNEY / PRO SE NAME 2. TELEPHONENUMBER( ) 3. COUNTY OF VENUE 4. FIRM NAME (If applicable) 5. DOCKET NUMBER (When available) 7. DOCUMENT TYPEVerified Complaint6. OFFICEADDRESS 8. JURY DEMAND YES NO 9. NAME OF PARTY (e.g. John Doe, Plaintiff) 10. CAPTIONIn Re the Petition of 11. CASE TYPE NUMBER(See reverse side for listing)15112. IS THIS A PROFESSIONAL MALPRACTICE CASE? YES NO IF YOU HAVE CHECKED "YES," SEE N.J.S.A. 2A:53A-27ANDAPPLICABLE CASE LAW REGARDING YOUR OBLIGATION TO FILEANAFFIDAVIT OF MERIT.13. RELATED CASES PENDING? YES NO14. IFYES, LIST DOCKET NUMBERS 15. DO YOU ANTICIPATE ADDING ANY PARTIES (arising YES NOout of same transaction or occurrence)?16. NAME OF DEFENDANT'S PRIMARY INSURANCE COMPANY, IF KNOWN NONE UNKNOWN THE INFORMATION PROVIDED ON THIS FORM CANNOT BE INTRODUCED INTO EVIDENCE. CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATIONIF YES, IS THATRELATIONSHIP EMPLOYER-EMPLOYEE FRIEND/NEIGHBOR OTHER(explain)17. A. DO PARTIES HAVE ACURRENT,PAST OR RECURRENTRELATIONSHIP? YES NO FAMILIAL BUSINESS 18. B. DOES THE STATUTE GOVERNING THISCASE PROVIDE FOR PAYMENT OF FEES YES NOBY THE LOSING PARTY?19. USE THIS SPACE TOALERTTHE COURTTOANY SPECIAL CASE CHARACTERISTICS THAT MAYWARRANT INDIVIDUAL MANAGEMENT OR ACCELERATED DISPOSITION:20. DO YOU OR YOUR CLIENT NEED IF YES, PLEASE IDENTIFY THEANY DISABILITYACCOMMODATIONS? YES NO REQUESTED ACCOMMODATION:21. WILL AN INTERPRETER BE NEEDED? YES NO IF YES, FOR WHAT LANGUAGE: 22. I certify that confidential personal identifiers have been redacted from documents now submitted to the court, and will be redacted from all documents submitted in the future in accordance with Rule 1:38-7(b).22. ATTORNEYSIGNATURE: Effective 09/01/2009, CN 10517_ps-English Page 2 of 2SIDE 2 CIVIL CASE INFORMATION STATEMENT (CIS) Use for initial pleadings (not motions) under Rule 4:5-1 CASE TYPES (Choose one and enter number of case type in appropriate space on the reverse side.) Track 1 - 150 days' discovery151NAME CHANGE175 FORFEITURE302TENANCY399REAL PROPERTY (other than Tenancy, Contract, Condemnation, Complex Commercial or Construction)502 BOOK ACCOUNT (debt collection matters only)505 OTHER INSURANCE CLAIM (INCLUDING DECLARATORY JUDGMENT ACTIONS)506PIP COVERAGE510 UM or UIM CLAIM511 ACTION ON NEGOTIABLE INSTRUMENT512LEMON LAW801 SUMMARY ACTION802OPEN PUBLIC RECORDS ACT (SUMMARY ACTION)999Other (Briefly describe nature of action)Track II - 300 days' discovery305CONSTRUCTION509EMPLOYMENT (other than CEPA or LAD)599 CONTRACT/COMMERCIAL TRANSACTION603 AUTO NEGLIGENCE - PERSONAL INJURY605 PERSONAL INJURY610 AUTO NEGLIGENCE - PROPERTY DAMAGE699TORT - OTHERTrack III - 450 days' discovery005 CIVIL RIGHTS301 CONDEMNATION602ASSAULT AND BATTERY604 MEDICAL MALPRACTICE606PRODUCT LIABILITY607PROFESSIONAL MALPRACTICE608TOXIC TORT609 DEFAMATION616 WHISTLEBLOWER / CONSCIENTIOUS EMPLOYEE PROTECTION ACT (CEPA) CASES617 INVERSE CONDEMNATION618 LAW AGAINST DISCRIMINATION (LAD) CASES620 FALSE CLAIMS ACTTrack IV - Active Case Management by Individual Judge / 450 days' discovery156 ENVIRONMENTAL COVERAGE LITIGATION303MT. LAUREL508 COMPLEX COMMERCIAL513COMPLEX CONSTRUCTION514INSURANCE FRAUD701 ACTIONS IN LIEU OF PREROGATIVE WRITCentrally Managed Litigation (Track IV)280 Zelnorm285Stryker Trident Hip ImplantsMass Tort (Track IV)248CIBA GEIGY 279GADOLINIUM266 HORMONE REPLACEMENT THERAPY (HRT) 281BRISTOL-MEYERS SQUIBB ENVIRONMENTAL271 ACCUTANE 282FOSAMAX272 BEXTRA/CELEBREX 283DIGITEK274 RISPERDAL/SEROQUEL/ZYPREXA 284 NUVARING275 ORTHO EVRA 286 LEVAQUIN277 MAHWAH TOXIC DUMP 601ASBESTOS278 ZOMETA/AREDIA 619VIOXXIf you believe this case requires a track other than that provided above, please indicate the reason on Side 1,in the space under "Case Characteristics."Please check off each applicable category: Verbal Threshold Putative Class Action Title 59

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