Statement Damages Form PDF Details

When you are injured, the last thing you want to worry about is filling out paperwork. The Statement Damages Form can help make the process a little easier. This form is designed to help document your injuries and any expenses related to them. Having this information available can make it easier to recover damages if you decide to pursue a claim. completion of this form will also provide some basic information that your insurance company may request during the claims process. Filling out this form can be tedious, but it is well worth the effort if it results in a successful claim.

You will discover more information about the statement damages form by checking out the table our team compiled.

QuestionAnswer
Form NameStatement Damages Form
Form Length2 pages
Fillable?Yes
Fillable fields90
Avg. time to fill out18 min 34 sec
Other namesstatement of damages form california, damages form, sample statement of damages california, statement of damages ca

Form Preview Example

 

 

- DO NOT FILE WITH THE COURT-

 

 

 

CIV-050

 

 

 

 

 

 

 

 

-UNLESS YOU ARE APPLYING FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE § 585 -

 

 

 

 

 

 

 

 

 

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address):

TELEPHONE NO.:

 

 

 

 

FOR COURT USE ONLY

 

 

 

 

 

 

 

To keep other people from

 

 

 

 

 

 

seeing what you entered on

 

 

 

 

 

 

your form, please press the

 

 

 

 

 

 

Clear This Form button at the

 

ATTORNEY FOR (name):

 

 

end of the form when finished.

 

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

 

 

 

 

 

 

 

STREET ADDRESS:

 

 

 

 

 

 

 

MAILING ADDRESS:

 

 

 

 

 

 

 

CITY AND ZIP CODE:

 

 

 

 

 

 

 

 

BRANCH NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLAINTIFF:

 

 

 

 

 

 

 

DEFENDANT:

 

 

 

 

 

 

 

 

CASE NUMBER:

 

 

 

 

 

 

STATEMENT OF DAMAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Personal Injury or Wrongful Death)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To (name of one defendant only):

 

 

 

 

 

 

 

Plaintiff (name of one plaintiff only):

 

 

 

 

 

 

 

seeks damages in the above-entitled action, as follows:

 

 

 

 

AMOUNT

1. General damages

 

 

 

 

 

 

 

 

 

 

 

a.

 

Pain, suffering, and inconvenience

 

 

$

 

 

 

 

 

 

b.

 

Emotional distress

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

Loss of consortium

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

d.

 

Loss of sociey and companionship (wrongful death actions only)

 

 

$

 

 

 

 

 

 

 

 

 

 

 

e.

 

Other (specify)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f.

 

Other (specify)

$

 

 

 

 

 

 

 

 

 

 

g.

 

Continued on Attachment 1.g.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Special damages

a. b.

c.

d. e.

f. g. h.

i.

j. k.

3.

Medical expenses (to date)

$

Future medical expenses (present value)

$

Loss of earnings (to date)

$

Loss of future earning capacity (present value)

$

Property damage

$

Funeral expenses (wrongful death actions only)

$

Future contributions (present value) (wrongful death actions only)

$

Value of personal service, advice, or training (wrongful death actions only)

$

Other (specify)

$

Other (specify)

$

Continued on Attachment 2.k.

 

Punitive damages: Plaintiff reserves the right to seek punitive damages in the amount of (specify).. $ when pursuing a judgment in the suit filed against you.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)

(Proof of service on reverse)

Page 1 of 2

Form Adopted for Mandatory Use

Judicial Council of California

CIV-050 [Rev. January 1, 2007]

STATEMENT OF DAMAGES

(Personal Injury or Wrongful Death)

Code of Civil Procedure, §§ 425.11, 425.115 www.courtinfo.ca.gov

f. Name, address and telephone number and, if applicable, county of registration and number:
(For California sheriff, marshal, or constable use only) I certify that the foregoing is true and correct.
Date:
(SIGNATURE)

PLAINTIFF:

DEFENDANT:

CIV-050

CASE NUMBER:

PROOF OF SERVICE

(After having the other party served as described below, with any of the documents identified in item 1, have the person who served the documents complete this Proof of Service. Plaintiff cannot serve these papers.)

1.I served the

a. Statement of Damages Other (specify):

b.on (name):

c. by serving

 

defendant

 

other (name and title or relationship to person served):

 

 

d.

 

by delivery

 

at home

 

 

at business

 

 

 

 

(1)date:

(2)time:

(3)address:

e. by mailing

(1)date:

(2)place:

2.Manner of service (check proper box):

a. Personal service. By personally delivering copies. (CCP § 415.10)

b.

 

Substituted service on corporation, unincorporated association (including partnership), or public entity. By

 

 

leaving, during usual office hours, copies in the office of the person served with the person who apparently was in

 

 

charge and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the

 

 

copies were left. (CCP § 415.20(a))

c. Substituted service on natural person, minor, conservatee, or candidate. By leaving copies at the dwelling house, usual place of abode, or usual place of business of the person served in the presence of a competent member of the household or a person apparently in charge of the office or place of business, at least 18 years of age, who was informed of the general nature of the papers, and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the copies were left. (CCP § 415.20(b)) (Attach separate declaration or affidavit stating acts relied on to establish reasonable diligence in first attempting personal service.)

d.

e.

Mail and acknowledgment service. By mailing (by first- class mail or airmail, postage prepaid) copies to the person served, together with two copies of the form of notice and acknowledgment and a return envelope, postage prepaid, addressed to the sender. (CCP § 415.30) (Attach completed acknowledgment of receipt.)

Certified or registered mail service. By mailing to an address outside California (by first-class mail, postage prepaid, requiring a return receipt) copies to the person served. (CCP § 415.40) (Attach signed return receipt or other evidence of actual delivery to the person served.)

f. Other (specify code section):

additional page is attached.

3.At the time of service I was at least 18 years of age and not a party to this action.

4.Fee for service: $

5.Person serving:

a.

 

California sheriff, marshal, or constable

 

b.

 

Registered California process server

 

 

Employee or independent contractor of a registered

c.

 

 

 

California process server

d.

 

Not a registered California process server

 

 

 

e.

 

Exempt from registration under Bus. & Prof. Code

 

 

§ 22350(b)

I declare under penalty of perjury under the laws of the

State of California that the foregoing is true and correct.

Date:

(SIGNATURE)

CIV-050 [Rev. January 1, 2007]

PROOF OF SERVICE

 

 

(Statement of Damages)

 

 

 

For your protection and privacy, please press the Clear This Form

 

 

 

Save This Form

button after you have printed the form.

 

 

 

 

 

 

Page 2 of 2

Code of Civil Procedure §§ 425.11, 425.115

Print This Form Clear This Form

How to Edit Statement Damages Form Online for Free

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Step 1: Hit the orange button "Get Form Here" on the web page.

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step 1 to writing ccp 425 11 statement of damages

You should put down your particulars within the part Other, specify Other, specify Continued, on, Attachment, g Special, damages and def, g, hi

step 2 to entering details in ccp 425 11 statement of damages

The system will ask you for particulars to automatically submit the area def, g, hi Date, Judicial, Council, of, California TYPE, OR, PRINT, NAME and Personal, Injury, or, Wrongful, Death

Filling out ccp 425 11 statement of damages stage 3

The PLAINTIFF, DEFENDANT, CASE, NUMBER CIV, PROOF, OF, SERVICE Statement, of, Damages Other, specify I, served, the a, bon, name, c, by, serving defendant, at, home at, business and Manner, of, service, check, proper, box box will be the place to insert the rights and obligations of both sides.

stage 4 to filling out ccp 425 11 statement of damages

Complete the file by looking at these particular sections: additional, page, is, attached and abc.

Entering details in ccp 425 11 statement of damages stage 5

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