Expedited Petition to Approve

EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY

Case Name: Case Number:

Expedited Petition to Approve:

Compromise of Disputed Claim

Compromise of Pending Action

Disposition of Proceeds of Judgment

Minor    Person With a Disability

No hearing date is requested.

Hearing Date: Dept.: Time:

1. Petitioner (name):

2. Claimant (name):

a. Address:

b. Date of birth: c. Age: d. Sex:

e. Minor    f. Person with a disability

3. Expedited petition

a. The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another.

b. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust.

c. There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.

d. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier.

e. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.

f. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court has finally determined that all settling parties entered into the settlement in good faith.

g.(1) The judgment or total settlement is $50,000 or less.

g.(2) The settlement represents payment of the single-person policy limits of all liability insurance policies covering the defendants.

4. Relationship Petitioner's relationship to the claimant (check all applicable boxes):

Parent    Guardian ad litem    Guardian    Conservator

Disabled adult claimant is a petitioner.

Disabled adult claimant's express consent is provided on Attachment 4f.

Other relationship (specify):

5. Nature of claim

a. Is not the subject of a pending action or proceeding.

b. Is the subject of a pending action or proceeding that will be compromised without a trial on the merits of the claim.

c. Is the subject of a pending action or proceeding that has been or will be reduced to a judgment for the claimant.

Court name: Case no.: Trial date:

Judgment filed on: Total amount (exclusive of interest and costs): $

Defendants (names):

6. Incident or accident

Date: Time:

Place:

Persons involved (names):

7. Nature of incident or accident

8. Injuries

9. Treatment

10. Extent of injuries and recovery

a. The claimant has recovered completely and there are no permanent injuries.

b. The claimant has not recovered completely and the remaining injuries are temporary.

c. The claimant has not recovered completely and the remaining injuries are permanent.

11. Investigation

12. Amount and terms of settlement

Total amount offered by all defendants: $

13. Settlement payments to others

No defendant has offered to pay money to any person other than the claimant.

One or more defendants have also offered to pay money to other persons.

Total amount offered to others: $

Petitioner would receive money under the proposed settlement.

14. Claimant's medical expenses

Total expenses: $

Total amount paid: $

Total negotiated reductions: $

Total amount to be paid or reimbursed from proceeds: $

Total amount of medical liens: $

None of the claimant's medical expenses have been paid by Medi-Cal.

Medi-Cal paid some or all of the claimant's medical expenses.

Notice of this claim or action has been given to the State Director of Health Care Services.

Notice filed on:

In full satisfaction of its lien rights, Medi-Cal agreed to accept: $

None of the claimant's medical expenses have been paid by Medicare.

Medicare paid some or all of claimant's medical expenses.

Medicare reimbursement amount: $

The claimant's health plan is requesting reimbursement.

Health plan reimbursement amount: $

Petitioner paid claimant's medical expenses to be reimbursed: $

15. Attorney's fees and other expenses

Total attorney's fees requested: $

Continued on Attachment 15b.

Costs of suit attributable to more than one settling plaintiff are not apportioned on a pro rata basis.

16. Reimbursement of expenses paid by petitioner

Petitioner has paid none of the claimant's expenses listed in items 14 and 15.

Petitioner has paid the following total amounts of the claimant's expenses.

Medical expenses listed in item 14: $

Attorney's fees included in item 15a: $

Other expenses included in item 15b: $

Total reimbursement: $

17. Net balance of proceeds for the claimant

Balance remaining after payment or reimbursement of all requested fees and expenses: $

18. Summary

Gross amount of proceeds: $

Medical expenses: $

Attorney's fees: $

Other expenses: $

Total fees and expenses: $

Balance available for claimant: $

19. Information about attorney representing or assisting petitioner

The attorney is not representing or employed by any other party involved in this matter.

The attorney is representing or employed by any other party involved in this matter.

The attorney has neither received nor expects to receive attorney's fees or other compensation in addition to that requested in this petition.

The attorney has received or expects to receive attorney's fees or other compensation in addition to that requested in this petition.

20. Disposition of balance of proceeds of settlement or judgment

a. Guardianship/conservatorship exists

There is a guardianship or conservatorship filed in:

Court name: Case no.:

Money or property will be paid or delivered to the guardian/conservator.

Petitioner requests authority to deposit or invest money or property subject to withdrawal only as authorized by the court.

Money will be invested in a single-premium deferred annuity.

Money will be transferred to a custodian under the California Uniform Transfers to Minors Act.

Money or property will be paid or delivered to a parent of the minor under Probate Code sections 3401–3402.

Money or property will be held on such conditions as the court determines is in the best interest of the minor or adult person with a disability.

Property other than money will be held on such conditions as the court determines is in the best interest of the minor or adult person with a disability.

Money will be deposited with the county treasurer.

Money or other property will be paid or transferred to the adult person with a disability.

21. Recommendation

22. Additional orders

23. Number of pages attached:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.