Complaint for Negligence

COMPLAINT FORM

IN THE COURT OF COUNTY

STATE OF

COMPLAINT

Comes now the Plaintiff, and files this complaint

against the Defendant, and for cause would show unto the

Court as follows, to-wit:

1. The Plaintiff is an adult resident citizen of County,

    whose address is

2. The Defendant is an adult resident citizen of County,

    whose address is

3. At all times herein mentioned, Defendant, was the

owner and operator of a automobile which is the

vehicle operated by in the incident complained of.

4. (Skip this paragraph if driver is not an employee of Defendant) On or about

day of 20 was the agent, servant

and employee of said Defendant and was operating the above-mentioned vehicle within the

scope of his employment as an employee of

5. On the date above mentioned, Plaintiff was operating his/ her automobile in a safe

and prudent manner and was proceeding on

road/highway.

6. (Skip unless plaintiff was a passenger) On the date above mentioned, Plaintiff,

was a passenger in said vehicle being driven by

in a direction on

road/highway. Due to the careless, reckless and negligent actions of

said vehicle was involved in a violent collision whereby as a proximate result thereof, Plaintiff

sustained severe and disabling injuries.

7. At the time herein complained of, the vehicle was operated by the Defendant who

caused all of which occurred without

fault or negligence on the part of the Plaintiff.

8. In addition to the above-mentioned acts of negligence, the collision was caused

by one or more of the following acts of negligence on the part of

(select applicable acts):

Failure to yield the right-of-way;

Failure to keep a proper lookout for other traffic;

Failure to maintain the proper degree of control of the vehicle;

Operating the vehicle in an unsafe, unreasonable, reckless or indiscriminate

    manner without due regard for the safety of others, including the Plaintiff;

Failure to avoid the collision.

9. As a proximate cause of the negligence of the Defendant, Plaintiff was caused,

and will be caused in the future, to suffer the following injuries and damages (select applicable

injuries/damages):

Medical, doctor, hospital and drug bills both in the past and reasonably

    anticipated in the future;

Loss of wage earnings and loss of wage earnings reasonably anticipated in the

    future;

Loss of wage earning capacity;

Permanent and disfiguring disability;

Severe pain and suffering in the past and the Plaintiff anticipates to experience

    severe pain and suffering in the future;

Severe pain and disfigurement and disabling injuries to his/ her body as a whole;

Deprivation of her/his ability to enjoy a normal life;

Mental anguish and shock to her/ his nervous system.

WHEREFORE, Plaintiff demands judgment of and from the Defendant,

a sum in excess of the jurisdictional amount of this Court,

together with all cost of court and interest from the date of the incident herein complained of

$

Respectfully submitted,

Dated:

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