Fill and Sign the Court Personal Injury Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT COMES NOW Plaintiff, _______________, and for cause of action against Defendants would respectfully show: 1. Plaintiff is an adult resident citizen of _______________ County, _______________, born the ____ day of _____________, 20___, and residing at _______________, _______________. Defendant _______________ is a corporation organized and existing under the laws of the State of _______________, doing business as _______________ with its principal place of business in _______________ County, _______________, and whose agent for service of process is _______________, at _______________, _______________. Defendant _______________ is a non-profit corporation organized under the laws of the State of _______________ with its principal place of business in _______________ County, and whose agent for service of process is _______________, at _______________, _______________. Defendant Unknown Corporation A ("Corporation A") is a corporation or other business - 1 - entity doing business in the State of _______________, but whose exact identity is unknown to Plaintiff at this time. Defendant Unknown Person John Doe ("Doe") is an adult resident citizen of the State of _______________, but whose identity and residence address are unknown to Plaintiff at this time. 2. On or about the evening of the _____ day of ___________, 20___, Defendant _______________ held its annual party on the premises of _______________ owned and operated by Defendant _______________ in _______________ County, _______________. During the course of said party, alcoholic intoxicating liquor and beverages was sponsored, provided, served and/or sold to attendees of said party, including but not limited to one _______________, deceased, with the knowledge and participation, individually, jointly and in concert of each and all of the Defendants. 3. During all times complained of herein, the serving, sale or consumption of alcoholic intoxicating liquor and beverages was contrary to, and in violation of, applicable statutes, ordinances, laws and regulations of the State of _______________ and _______________ County. 4. On the occasion complained of, Defendants _______________, _______________, Corporation A and Doe, individually, jointly and/or in concert, sponsored, supplied, served and/or sold alcoholic intoxicating liquors and beverages to said _______________, deceased, then an adult resident citizen of _______________ County, _______________, both prior to and after the time that said _______________, deceased became visibly and dangerously intoxicated. 5. Immediately upon leaving said _______________ party, while still in a drunken and highly intoxicated state, said _______________, deceased, began driving and operating his - 2 - motor vehicle in a drunken, reckless and dangerous manner while proceeding south across _______________ Road, whereupon he drunkenly and recklessly swerved his vehicle into the opposite or wrong lane of said road and collided head on with a vehicle being driven by Plaintiff _______________. At the time of said collision, and at all times immediately prior thereto, Plaintiff was operating her said vehicle in a lawful, safe and reasonable manner, and in compliance with all applicable rules of the road and traffic rules and regulations. 6. On the occasion complained of Defendant _______________, _______________, Corporation A and Doe were negligent in that they, acting individually, jointly and/or in concert as aforesaid, provided, supplied, sponsored, encouraged, served and/or sold intoxicating alcoholic beverages and liquor to said _______________, deceased: (a) At a time when said Defendants, and each of them, reasonably knew, or should have known that said _______________ had become intoxicated to such an extent as to represent a danger to the public including Plaintiff _______________. (b) In violation of the statutes, ordinances, laws and regulations of the State of _______________ and _______________ County designed to protect the public and that class of people including Plaintiff _______________. 7. As a direct and proximate result of the negligence of Defendants _______________, _______________, Corporation A and Doe, as aforesaid, which proximately caused or contributed to the afore described collision, Plaintiff _______________ sustained serious injuries, losses and damages as follows: (a) Serious and painful personal injuries including but not limited to contusions, lacerations, concussions, broken bones, abrasions and burns to her body; (b) Permanent physical disability and limitations to functions of her body; - 3 - (c) Serious, painful and permanent scarring and disfigurement from said trauma and burns to her body; (d) Extreme mental and physical pain, suffering, anxiety, anguish and upset; (e) Permanent loss and damage to her quality of life and mental and emotional well being; and (f) Reasonable and necessary doctor, hospital, dental, medical and related bills and expenses in excess of $____________. 8. The negligence of Defendants _______________, _______________, Corporation A and Doe as aforesaid, was so gross, willful, intentional and in such reckless disregard for the safety of Plaintiff, and persons similarly situated, so as to warrant the imposition of punitive damages. WHEREFORE, PREMISES CONSIDERED, Plaintiff _______________ demands judgment of and from Defendants _______________, _______________, Corporation A and Doe, jointly and severally, in the amount of $_______________ actual damages and $_______________ punitive damages. Respectfully submitted, Dated: Name:       Title:       Address:       Address:       City, State, Zip:       Phone:       Fax:       E-Mail:       Attorney No.:       - 4 - 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____. _________________________________ - 5 -