Fill and Sign the Complaint Regarding Wrongful Death Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT (WRONGFUL DEATH) COMES NOW the Plaintiff(s), [ insert names of plaintiff(s) ], by counsel, and for his/her Complaint against the Defendant(s), [ insert name of defendant(s) ], alleges and states: PARTIES 1. The Plaintiff(s), [ insert names of all wrongful death heirs & beneficiaries ] at all times relevant hereto, is/are adult citizens of the State of [ insert state jurisdiction] and reside in [ insert county name ], and are the heirs and wrongful death beneficiaries of the decedent, [ insert decedent’s name ] (hereinafter referred to as Plaintiffs). 2. The Defendant(s), [ insert names of each defendant ] at all times relevant hereto, is: (INSERT 1 OR MORE OF THE FOLLOWING) (a) A corporation incorporated under the laws of the State of [ insert state of incorporation] and is [or is not ] authorized to do business as a foreign corporation in this State, and is subject to service of process by and through its registered agent: [ insert name and address of registered agent ]; - 1 - (b) An adult citizen of the State of [ insert defendant’s state of residency ] who resides at [ inserts defendant’s street address, city and zip code ] and is subject to service of process pursuant to the laws of the State of [ e.g., state of filing, or long-arm statute or non-resident motorist statute if diverse jurisdiction ]. FACTS 3. On or about [ insert date ] the decedent [ insert decedent’s name ] was a(n) [ insert the decedent’s status and relationship to defendant, e.g., licensee, invitee, employee, etc. ]. 4. At all times relevant hereto, the decedent [ insert facts of case describing the decedent’s location and activities, circumstances, conditions, transactions or occurrences leading up to decedent’s death ]. 5. At all times relevant hereto, the Defendant(s): [ insert facts of case describing each of the defendant’s degrees of ownership or control over the premises, activities, methods, circumstances, conditions, transactions or occurrences causing or contributing to the decedent’s death ]. 6. On [ insert date of decedent’s death ] the decedent died by: [ insert facts describing the manner of death, nature of injuries, extent of suffering, etc. ]. The conduct of Defendant(s) complained of herein was: [ insert nature of conduct, e.g., malicious, outrageous, intentional, egregious, willful, wanton, reckless, etc. ]. CLAIMS COUNT I: 7. The Defendant(s) had a duty: [insert legal duty of defendant, e.g., business owner has a duty to: (a) Keep its premises in a reasonably safe condition; - 2 - (b) To take steps reasonably calculated to remove hazardous and dangerous conditions on its premises; (c) To warn of any dangerous and hazardous conditions of which the business owner has either actual or constructive knowledge]. 8. The Defendant(s) breached the duties delineated hereinabove proximately causing or proximately contributing to the death of the decedent. 9. As a direct and proximate result of breach of the duties alleged hereinabove, the decedent suffered: [ insert the types of damages claimed, e.g., present net cash value of life; personal injury, pain & suffering notwithstanding instantaneous death; loss of society & companionship, medical & burial expenses, etc. ]. COUNT II: 10. The conduct of Defendant(s) complained of hereinabove constitutes: [ insert theory of liability, e.g., gross negligence, reckless disregard for safety of others, etc. ] for which the Defendant(s) should be punished and deterred from similar conduct in the future. DEMAND FOR RELIEF: WHEREFORE, the Plaintiffs pray for the following relief: (a) Trial by jury; (b) Judgment for Plaintiff(s) and against the Defendant(s); (c) An award of damages in an amount which will fully and fairly compensate Plaintiffs for [ insert types of damages from claims section ]. (d) An award of punitive damages in amount which is reasonably and rationally related to the egregiousness of Defendant’s conduct, and which is reasonably and rationally related to the financial net worth of the Defendant(s), and which is in the public interest; - 3 - (e) Reasonable attorney fees, costs and expenses ( if allowed by jurisdiction ); (f) Such other and further relief as may be deemed just and proper in the premises. Respectfully submitted, Dated: Name:       Title:       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 -