Fill and Sign the Truck Accident Sample Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT COME NOW Plaintiffs ________________________ and ________________________, by and through counsel, ______________________, and file this Complaint against ______________________ and ____________________, and in support thereof set forth the following: 1. ________________________ is an adult resident citizen of _________________ County, _________________, residing at ___________________________________________. 2. ________________________ is an adult resident citizen of _________________ County, _________________, residing at ___________________________________________. 3. Defendant ____________________ is a ________________ Corporation, licensed and doing business in the State of ___________________, who may be served with process through its agent, ______________________, at _________________________________, _________________. - 2 - 4. Defendant _______________________ was the agent, servant and employee of Defendant ____________________________ 5. During all the times herein mentioned Defendant ________________________ was the owner of an eighteen wheel Mack truck, herein after “truck”, which at the time of the accident hereinafter described was being driven by _______________________, an employee of Defendant ______________________, during the course and scope of his employment for _______________________ with the express permission and consent and for the benefit of _______________________. 6. As a result, Defendant ______________________ is responsible both for ___________________ actions and conduct pursuant to the doctrine of respondeat superior and for any negligence of its own. 7. On _____ day of ___________, 20____, at about _______ a.m./p.m., the Plaintiff ____________________________ was operating an automobile owned by him/her in a ____________ direction on _______________ road/highway in _______________ County, ________________, approaching ________________________. 8. As Plaintiff _____________________ approached _______________________, it ___________________________ and Plaintiff _________________________________. 9. Defendant ____________________ approached the Plaintiff's car from behind and failed to stop, suddenly and violently striking the Plaintiff's car from the rear. 10. Said collision was the proximate cause of property damage to Plaintiff ______________________'s car, temporary injuries to Plaintiff and serious and permanent injuries to Plaintiff ________________________ - 3 - 11. Plaintiff ______________________ at all times during the occurrence hereinbefore set forth used due care and caution and was completely free from any and all negligence in any manner contributing to her injuries and damages as herein complained of. 12. Said collision was due to Defendant _______________________'s negligence in that he/she was not keeping a reasonable lookout, did not have his truck under proper control, and was otherwise guilty of carelessness and negligence in the operation of that motor vehicle. 13 Plaintiffs allege that the proximate cause of the aforementioned collision was t he negligence of Defendant _____________________, for which negligence he must stand during the course and scope of his employment for _________________________, with the express permission and consent and for the benefit of _________________________. 14. Plaintiffs allege that the proximate cause of the aforementioned collision was t he negligence of Defendant ___________________, for which negligence he must stand responsible together with his employer and its liability carrier, jointly and severa lly, said negligence including, but not limited to, the following acts and omissions: a. Failure to keep a proper lookout; b. Failure to maintain a safe speed; c. Any and all other negligent acts and/or omissions which may be shown during the course of these proceedings. 15. Plaintiffs allege that the proximate cause of the aforesaid collision was the negligence of Defendant __________________________, and for which negligence it must stand responsible together with its liability carrier, jointly and severally, said negli gence including, but not limited to, the following acts and omissions: a. Negligent entrustment of an oversized motor vehicle; and - 4 - b. Any and all other negligent acts and/or omissions which may be shown during the course of these proceedings. 16. As a result of the aforesaid collision, Plaintiff ______________________ suffered physical injuries requiring medical treatment, and Plaintiff _______________________ suffered temporary total disability and partial permanent disability. 17. As a result of the aforesaid collision, Plaintiff ______________________ suffered emotional trauma and distress and incurred expenses and lost income. 18. As a result of the aforesaid collision, Plaintiff ______________________ will continue to suffer the aforesaid damages and, further, will continue to incur medical expenses in the future. 19. Because of the injuries suffered in the collision by his wife, Plaintiff ______________________ has lost and been deprived of the services of his wife, including loss of society, companionship, consortium, and he will continue to be permanently so deprived of as a result of the injuries suffered by Plaintiff ___________________. WHEREFORE, PREMISES CONSIDERED, Plaintiffs pray that Defendants, _______________________ and _____________________ each be served with process of this Court, to appear and answer same, and that after due proceedings be had there be judgm ent herein in favor of Plaintiffs and against Defendants, jointly and severally, in the am ount of _____________________ Dollars ($_________) with interest from the date of judicial demand until paid, for all costs of these proceedings and for any and all other legal and equit able relief to which they may be entitled. And, Plaintiffs pray for general relief - 5 - Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: 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____. _________________________________