Fill and Sign the Negligence Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT 1. ___________________ is an adult resident citizen of __________ County, ____________, residing at ______________________________________, ____________. 2. ___________________ is an adult resident citizen of __________ County, ____________, residing at ______________________________________, ____________. 3.___________________ resides with her mother and father at ______________________________________, ____________. 4.___________________ (hereinafter referred to as ___________________ ) is a ___________ Corporation, authorized to do business in ____________, and may be served with summons and a copy of the Complaint by service upon their designated agent for service of process, who is ___________________ , located at ______________________________________, ____________. 5.___________________ and ___________________ were at all times material to this Complaint employees or agents of ___________________ and were acting in the course and - 2 - scope of their employment when the incident in question occurred. They may be served with summons and a copy of the complaint at ______________________________________, ____________. Facts 6. On or about the ______ day of _____________, 20____, the Plaintiffs were walking to a neighbor's home on Highway ________ when the Defendants' negligence caused serious injuries to the Plaintiffs. The Defendant's vehicle ran over a group of downed power lines, which in turn snapped up and seriously injured the Plaintiffs. 7. As a proximate result of the negligence of the Defendants, the Plaintiffs were caused to suffer the following injuries and damages: Plaintiff _______________________: A. Left foot injury; B. Broken knee; C. Loss of past wages; D. Medical bills exceeding ______________ Dollars and No/00 ($_________); E. Past and future pain and suffering; F. Permanent disability; G. Increased risk of arthritis or other future bone and joint deterioration; H. Diminished enjoyment of life. Plaintiff _______________________: A. Neck injury; B. Loss of past wages; C. Medical bills exceeding _______________ Dollars and No/00 ($_________); D. Past and future pain and suffering; - 3 - E. Diminished enjoyment of life. Plaintiff _______________________: A. Acute mental distress; B. Past and future pain and suffering; C. Left foot injury; D. Medical bills exceeding _______________ Dollars and No/00 ($_________) WHEREFORE PREMISES CONSIDERED, the Plaintiffs demand judgment of and from the Defendants in the amount of _______________ Dollars and No/00 ($_________) for Plaintiff _______________________; _______________ Dollars and No/00 ($_________) for Plaintiff _______________________; and _______________ Dollars and No/00 ($_________) for Plaintiff _______________________ . Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 4 - 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____.