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1 23456789 10111213141516171819202122232425 262728 - 1 - [INSERT CAPTION AND STYLE] COMPLAINT (WRONGFUL DEATH SINGLE COUNT) 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 ]. 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 ]; (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 the 1 23456789 10111213141516171819202122232425 262728 - 2 - defendant's ownership or control over the premises, activities 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. ]. CLAIMS: 7. The Defendant(s) had a duty: [ insert legal duty of defendant, e.g., business owner has a duty to: (1) keep its premises in a reasonably safe condition; (2) to take steps reasonably calculated to remove hazardous and dangerous conditions on its premises; (3) 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. ]. DEMAND FOR RELIEF: WHEREFORE, the Plaintiffs pray for the following relief: 1. Trial by jury; 2. Judgment for Plaintiff(s) and against the Defendant(s); 3. An award of damages in an amount which will fully and fairly compensate Plaintiffs for [ insert types of damages from claims section ]. 4. Reasonable attorney fees, costs and expenses ( if allowed by jurisdiction); 5. Such other and further relief as may be deemed just and proper in the premises.