Fill and Sign the Complaint for Damages Form

-1- 1 2 34 5 6 7 8 9 101112 13 1415 16 17 18 19 20 21 22 2324 25 262728 (Name, Address Of Party or attorney) _____________________________ _____________________________ _____________________________ State Bar No: __________________ (____) _____ - _________________ Attorney for _______ (Or "In Pro Per") SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF ________ PLAINTIFF(S) NAMES )CASE NO.: _______Plaintiffs ) ) v) ) DEFENDANT(S) NAMES ) Defendants) ) --------------------------------------------------------- COMPLAINT FOR DAMAGES (Wrongful Death) Plaintiff complains and for causes of action alleges as follows: FIRST COUNT(Negligence) I. The only surviving heirs of __________ [name], deceased (referred to in this complaint as "decedent"), are: Name: Address: Relationship Age: to Decedent: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ -2- 1 2 34 5 6 7 8 9 101112 13 1415 16 17 18 19 20 21 22 2324 25 262728 __________ __________ __________ __________ II. Plaintiffs are the surviving heirs at law of the decedent. __________ [Plaintiff __________ (name) is the surviving spouse of the decedent and plaintiff __________ (name) is the surviving minor child of decedent.] III. __________ [Add if applicable: For the purposes of this action, __________ (name) was duly appointed guardian ad litem of plaintiff __________ (name of minor child) on __________ (date) by order of this court. A copy of the order is attached and incorporated by reference.] IV. __________ [Add if applicable: __________ (Names of heirs) are joined as defendants in this action pursuant to section 382 of the Code of Civil Procedure for the reason that __________ [state why the heirs are not named as plaintiffs, such as: their consent to be joined as plaintiffs was sought and refused.] V. Plaintiffs do not know the true names of defendants DOES 1 through 50, inclusive, and therefore sue them by those fictitious names. __________ [Optionally, in addition to language in charging allegations that includes fictitiously named defendants: Plaintiffs are informed and believe, and on the basis of that information and belief allege, that each of those defendants was in some manner negligently and proximately responsible for the events and happenings alleged in this complaint and for plaintiffs' damages.] VI. Plaintiffs are informed and believe, and on the basis of that information and belief allege, that at all times mentioned in this complaint, defendants were the agents and employees of their -3- 1 2 34 5 6 7 8 9 101112 13 1415 16 17 18 19 20 21 22 2324 25 262728 codefendants, and in doing the things alleged in this complaint were acting within the course and scope of that agency and employment. VII. Defendant __________ [name of manufacturer] is now, and at all times mentioned in this complaint was, a corporation organized and existing under the laws of the State of California, with its principal place of business in __________ County, California. VIII. Defendant __________ [name of manufacturer] is now, and at all times mentioned in this complaint was, in the business of designing, manufacturing, constructing, and assembling __________ [type of product] for use by members of the general public. IX. Defendant __________ [name of retailer] is now, and at all times mentioned in this complaint was, a corporation organized and existing under the laws of the State of California, with its principal place of business in __________ County, California. X. Defendant __________ [name of retailer] is now, and at all times mentioned in this complaint was, in the business of selling __________ [type of product] for use by members of the general public. XI. Sometime prior to __________ [date], decedent purchased from defendant __________ [name of retailer] a __________ [describe specific product, giving model number, serial number, or other identifying information] made by defendant __________ [name of manufacturer] for the sum of $_____. XII. At all times mentioned in this complaint, defendants and each of them so negligently and carelessly designed, manufactured, constructed, assembled, and sold the __________ [product] described above that it was dangerous and unsafe for its intended uses. -4- 1 2 34 5 6 7 8 9 101112 13 1415 16 17 18 19 20 21 22 2324 25 262728 XIII. As a direct and proximate result of defendants' negligence and carelessness as described above, decedent was seriously injured on __________ [date], while using the __________ [product] in the manner for which it was intended. XIV. The injuries so inflicted on the decedent resulted in the decedent's death on __________ [date]. XV. As the direct and proximate result of the foregoing and the death of the deceased, plaintiff __________ [name of surviving spouse] has been deprived of a kind and loving spouse and of __________ [his or her] care, comfort, society, protection, love, companionship, affection, solace, moral support, loss of marital consortium, physical assistance in the operation and maintenance of the home, and financial support. XVI. As a further direct and proximate result of the foregoing death of the deceased, plaintiff __________ [name of minor heir] has been deprived of a kind and loving parent and of __________ [his or her] care, comfort, love, protection, advice, society, physical assistance, and financial support. XVII. As a further direct and proximate result of the foregoing, plaintiffs have been generally damaged in a sum to be established according to proof, as provided by Code of Civil Procedure sections 425.10 and 425.11. XVIII. As a further direct and proximate result of the death of the deceased, plaintiffs have incurred reasonable and necessary expenses for decedent's funeral, burial, and memorial services to their damage in a presently unascertained sum. Plaintiffs request permission to insert the amount when it is finally determined. -5- 1 2 34 5 6 7 8 9 101112 13 1415 16 17 18 19 20 21 22 2324 25 262728 WHEREFORE, plaintiffs demand judgment as set forth below. SECOND COUNT (Strict Products Liability) XIX. Plaintiffs incorporate by this reference each and all of the allegations contained in Paragraphs 1 through 18 of the First Count of this complaint as though fully set forth here. XX. At all times mentioned in this complaint, the __________ [product] and its component parts were defective as to design, manufacture, and warnings, causing the __________ [product] and its component parts to be in a defective condition that made them dangerous and unsafe for their intended uses. XXI. As a direct and proximate result of the dangerous and defective condition of the __________ [product] as described above, decedent was seriously injured on__________ [date], while using the __________ [product] in the manner for which it was intended.WHEREFORE plaintiffs demand judgment against defendants, and each of them, jointly and severally, as follows:For general damages according to proof;For special damages according to proof;For costs of suit;For pre judgment interest and post-judgment interest according to law; and -6- 1 2 34 5 6 7 8 9 101112 13 1415 16 17 18 19 20 21 22 2324 25 262728 For such other and further relief as the court may deem just and proper. DATE: ____________________ ____________________ (Signature) VERIFICATIONI, ___, am a ___in the above-entitled action. I have read the foregoing ___and know the contents thereof. The same is true of my own knowledge, except as to those matters which are therein alleged on information and belief, and as to those matters, I believe it to be true.I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed at , California. DATE: ____________________ ____________________ (Signature)