Fill and Sign the Complaint Auto Accident 497426600 Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT Comes now the Plaintiff, __________________________, and files this complaint against the Defendant, ___________________________, and for cause would show unto the Court as follows, to-wit: 1. The Plaintiff is an adult resident citizen of _______________County, _________________, whose address is _____________________________________________. 2. The Defendant is an adult resident citizen of ________________ County, _________________, whose address is _____________________________________________. 3. At all times herein mentioned, Defendant, _____________________, was the owner and operator of a _______________ (describe automobile) automobile which is the vehicle operated by _____________________ in the incident complained of. 4. (Skip this paragraph if driver is not an employee of Defendant) On or about ______ day of _______________, 20___, _______________________ was the agent, servant and employee of said Defendant and was operating the above-mentioned vehicle within the scope of his employment as an employee of ___________________________. - 1 - 5. On the date above mentioned, Plaintiff was operating his/ her automobile in a safe and prudent manner and was proceeding _______________ on ______________________ road/highway. 6. (Skip unless plaintiff was a passenger) On the date above mentioned, Plaintiff, ________________________, was a passenger in said vehicle being driven by ________________________ in a ________________ direction on ___________________ road/highway. Due to the careless, reckless and negligent actions of ______________________, said vehicle was involved in a violent collision whereby as a proximate result thereof, Plaintiff sustained severe and disabling injuries. 7. At the time herein complained of, the vehicle was operated by the Defendant who caused ____________________________________________, all of which occurred without fault or negligence on the part of the Plaintiff. 8. In addition to the above-mentioned acts of negligence, the collision was caused by one or more of the following acts of negligence on the part of _________________________ (select applicable acts) : Failure to yield the right-of-way; Failure to keep a proper lookout for other traffic; Failure to maintain the proper degree of control of the vehicle; Operating the vehicle in an unsafe, unreasonable, reckless or indiscriminate manner without due regard for the safety of others, including the Plaintiff; Failure to avoid the collision. 9. As a proximate cause of the negligence of the Defendant, Plaintiff was caused, and will be caused in the future, to suffer the following injuries and damages (select applicable injuries/damages) : - 2 - Medical, doctor, hospital and drug bills both in the past and reasonably anticipated in the future; Loss of wage earnings and loss of wage earnings reasonably anticipated in the future; Loss of wage earning capacity; Permanent and disfiguring disability; Severe pain and suffering in the past and the Plaintiff anticipates to experience severe pain and suffering in the future; Severe pain and disfigurement and disabling injuries to his/ her body as a whole; Deprivation of her/his ability to enjoy a normal life; Mental anguish and shock to her/ his nervous system. WHEREFORE, Plaintiff demands judgment of and from the Defendant, ________________________, a sum in excess of the jurisdictional amount of this Court, together with all cost of court and interest from the date of the incident herein complained of $__________. Respectfully submitted, Dated: Name:       Title:       Address:       Address:       City, State, Zip:       Phone:       - 3 - 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 -