Fill and Sign the Death Automobile Accident Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT Comes now plaintiff, _______________, mother and legal representative of the heirs of _______________, deceased, and files this action for wrongful death against the defendant, _______________ and _______________, and states as follows: 1. The plaintiff is an adult resident citizen of _______________ County, _______________. 2. Defendant, _______________, is a foreign corporation organized and existing under the laws of a state other than _______________, but is qualified to do and is doing business in the state of _______________. Said defendant can be served with process through its registered agent, _______________, of _______________, _______________. 3. Jurisdiction and venue are proper in this court. - 1 - 4. On or about the ____ day of _____________, 20___, at approximately _____ p.m., the deceased, _______________, was traveling in a _______________ on _______________ Road in _______________ County, _______________, which runs in a northerly and southerly direction. 5. As the decedent, _______________, traveled in a southerly direction on _______________ Road, he approached a railroad crossing that intersected said road at a ninety- degree angle. The _______________’s vehicle was struck by a train owned and operated by _______________. As a result of the collision between the vehicle and the _______________ train operated by an employee of _______________, _______________ was killed. 6. The death of _______________ was a direct result of the negligence of the defendant, the _______________ and its employee driver of the train who was an agent of _______________ at all relevant times. 7. The defendant was guilty of the following acts of negligence: a. Operating the train at an excessive rate of speed; b. Reckless operation of the train; c. Failure to keep a proper lookout for oncoming traffic; d. Failure to have proper warning signs and signals at a known dangerous railroad crossing; - 2 - e. Maintaining an extra - hazardous grade crossing at the location on _______________ Road in _______________ County, _______________ in that: (1) There were trees, shrubbery, brush and other vegetation on the railroad right of way which obstructed the visibility of motorists along the railroad tracks; (2) There were trees, shrubbery, brush and other vegetation on the railroad right of way which obstructed the visibility of the train crew looking for motorists approaching and crossing the railroad tracks; (3) There were no gates, proper flashing lights or other protective devices necessary to warn motorists of an approaching train; f. Failure to acquire reduced speed of its trains traversing and crossing in light of the above circumstances at said crossing. _______________, acting by and through its driver, negligently operated its locomotive and train contrary to all applicable duties and failed to exercise reasonable care under the circumstances then and there existing at the _______________ Road crossing so as to avoid injury and damage to persons using said crossing. 8. As a result of the negligence described above of the defendant, the plaintiff’s decedent was killed and his automobile was destroyed. 9. - 3 - The plaintiff demands judgment for loss of society and companionship of the decedent, medical and funeral bills, the total destruction of the automobile, the decedent's pain and suffering, hedonic damages, and loss of enjoyment of life. WHEREFORE, the plaintiff demands judgment from and against the defendant, _______________ and _______________ in the amount of _______________ ($_______________) for actual and punitive damages. 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 -