Legal Negligence Claim Form

LEGAL NEGLIGENCE CLAIM FORM

Claimant Name:   Claimant Address:

Respondent Name:   Respondent Address:

Claim Filing Date:   Incident Date:   Location of Incident:

RECITALS

WHEREAS, Claimant alleges that Respondent owed Claimant a legal duty of care in relation to the circumstances described herein and that Claimant suffered loss as a proximate result of Respondent's acts or omissions; and

WHEREAS, the incident giving rise to this claim occurred on or about at or near ; and

WHEREAS, Claimant seeks to preserve and document its factual and legal allegations, itemize damages, and provide Respondent with notice of Claimant's demands for recovery;

NOW THEREFORE, Claimant sets forth the following claim, allegations, and demand for relief:

1. ALLEGATIONS OF NEGLIGENCE

1.1 Duty. Claimant alleges that Respondent owed Claimant a duty to act with reasonable care under the circumstances, including but not limited to the duty to maintain premises, operate vehicles, supervise individuals, or perform professional services in a manner consistent with applicable standards.

1.2 Breach. Describe how Respondent breached the duty of care (acts or omissions):

1.3 Causation. Explain how Respondent's breach was a proximate cause of Claimant's injuries or losses (link facts to harm):

1.4 Damages — General Statement. State the nature of Claimant's injuries and general categories of damage (medical, economic, non-economic):

2. ITEMIZED DAMAGES

3. SUPPORTING DOCUMENTS

The following documents are attached or will be provided to support this claim (check applicable items):

Medical records and bills

Photographs or video of incident or injuries

Police, incident, or accident report

Witness statements and contact information

Billing, receipts, and wage statements

4. DEMAND FOR RELIEF

Claimant hereby demands monetary recovery in the amount of: and/or other relief as described below.

5. NOTICES

6. REPRESENTATIONS, WARRANTY AND CERTIFICATION

By submitting this form, Claimant certifies that the statements and information contained herein are true and correct to the best of Claimant's knowledge and belief. Claimant warrants that no material fact has been knowingly omitted and that Claimant has provided all documents in Claimant's possession that are relevant to the claim unless otherwise stated. Claimant acknowledges that knowingly submitting false or fraudulent information may subject Claimant to civil liability and other penalties as provided by law.

Claimant authorizes Respondent or Respondent's agents to obtain and review records reasonably necessary to evaluate the claim. Claimant further authorizes the release of medical, employment, and billing records to the extent necessary to verify damages and losses alleged herein.

I certify and authorize as stated above.

7. MISCELLANEOUS PROVISIONS

Governing Law. This claim and any settlement or resolution shall be governed by and construed in accordance with the laws of the state in which the incident occurred, without regard to conflict-of-law principles.

Entire Agreement. This form, together with any attachments and subsequent written agreements executed by the parties, constitutes the entire statement of Claimant's claim and supersedes all prior statements or agreements concerning the subject matter hereof.

Severability. If any provision of this form is held to be invalid or unenforceable, such invalidity or unenforceability shall not affect the remaining provisions, which shall continue in full force and effect.

Amendment and Waiver. Any amendment or waiver of any provision of this form must be in writing and signed by the party to be charged. The failure of any party to insist upon strict performance of any provision shall not be deemed a waiver of future enforcement of that or any other provision.

Counterparts. This form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

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