Statement of Claim- sample Claim Form and Particulars of Claim PDF

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This is a sample claim form and POC for the claimant bringing proceedings for the first time- details the particulars of the claim, relevant law, damages and schedule of past and future loss expenses....

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Civil Litigation and Dispute Resolution Commencing proceedings SA6 CF and PoC example

IN THE COUNTY COURT

Claim No. CYJ4697

BETWEEN:

Miss JUDITH EMILY LEWIS

Claimant

and Mr PHILIP JOHN RUSSELL

Defendant

___________________________________________ PARTICULARS OF CLAIM ____________________________________________

1. On 9 July 2015, the Claimant was a front seat passenger in a Vauxhall Astra motor car, registration number AE07 KHX ("the Vauxhall Astra"), driven by one Andrew Thomas Williamson along the A583 in the direction of Blackpool near Great Plumpton. This section of the A583 is subject to a 60 mph speed limit. 2. At about 10.30 am the Defendant, the owner and driver of a BMW 320i motor car registration number DL56 LTB, was travelling along the A583 towards Kirkham. 3. While attempting to overtake a line of 5 or more vehicles the Defendant crossed into the on-coming lane in his BMW 320i and accelerated to an excessive speed disregarding the presence of the Vauxhall Astra being driven by Andrew Thomas Williamson in the on-coming lane. 4. While attempting the manoeuvre described in paragraph 3 above the Defendant’s BMW 320i collided with the Vauxhall Astra causing the Vauxhall Astra to over-turn. 5. The collision was caused by the negligence of the Defendant. PARTICULARS OF NEGLIGENCE The Defendant was negligent in that he: a. drove too fast; b. drove on the wrong side of the road; c. failed to keep any or any proper look-out or have any or any sufficient regard to oncoming traffic on the road, and in particular the Vauxhall Astra; d. overtook or attempted to overtake a line of traffic when it was unsafe and/or dangerous to do so; e. failed to return to his lane when he saw or should have seen the approach of the Vauxhall Astra; f. failed to stop, slow down, steer or otherwise control his car as to avoid the collision. 6. Further, the Claimant will rely on the conviction of the Defendant on 15 February 2016 by the Blackpool Magistrates’ Court of the offence of driving the BMW 320i motor car on the A583 without due care and attention contrary to section 3 of the Road Traffic Act 1988. The conviction is relevant to the issue of negligence. Although the Defendant pleaded “Not Guilty” the justices found the case proved and no appeal was entered.

7. By reason of the collision the Claimant has suffered pain and injury and has sustained loss and damage. PARTICULARS OF INJURIES a. b.

Fracture to left wrist. Severe bruising across chest and abdomen.

The Claimant was born on 18 December 1998 and was 16 years of age at the date of the accident. Further particulars of her injuries will be given when medical evidence is available. PARTICULARS OF SPECIAL DAMAGE The Claimant’s losses are set out in the Schedule of Past and Future Loss and Expense served with these Particulars of Claim in compliance with the Civil Procedure Rules 1998 and Practice Direction 16, para 4.2. 8. Further, the Claimant claims interest pursuant to section 69 of the County Court Act 1984 on the amount found to be due to her at such rates and for such periods as the Court thinks fit. AND the Claimant claims: 1. Damages 2. Interest pursuant to section 69 of the County Courts Act 1984 to be assessed. HEATHER CAHILL STATEMENT OF TRUTH I believe that the facts stated in these Particulars of Claim are true. Signed:

J. Lewis

JUDITH EMILY LEWIS Dated this 15 June 2020

IN THE COUNTY COURT

Claim No. CYJ4697

BETWEEN: Miss JUDITH EMILY LEWIS

Claimant

and Mr PHILIP JOHN RUSSELL

Defendant

___________________________________________ CLAIMANT’S SCHEDULE OF PAST AND FUTURE LOSS AND EXPENSE AT 15 JUNE 2020 ____________________________________________ ITEM Past Loss and Expense (1) Prior to the accident, the Claimant was employed as a Catering Assistant at a wage of £293 per week net. The Claimant was unable to return to work, and her contract of employment was terminated with effect from 1 August 2015. She was unemployed until 11 December 2016 (71 weeks). £293 x 71 weeks

AMOUNT

£20,803

(2) Since 12 December 2016 the Claimant has been employed as a Catering Assistant, but lost 18 months’ seniority, equivalent to approximately £26.00 net per week. From 12 December 2015 to 15 June 2020 (3 years and 25 weeks) £26 x 181 weeks.

£4,706

(3) Damaged clothing comprising: Blouse Skirt Shoes Sub total Total Past Loss and Expense

Future Loss and Expense (4) Continuing loss of seniority as an employee in the

£19.50 £36.00 £47.50 £103.00 £25,612

catering industry at £26.00 net per week, equivalent to £1,352 net per annum. (a) The Claimant is likely to retire at the age of 65, and the appropriate multiplier is 45.80. £1,352 x 45.80 =

£61,921.60

(b) The appropriate adjustment using Table C of the Ogden Tables, paras 38-42 is 0.68. Future loss

=

£61,921.60 x 0.68

£42,106.69

STATEMENT OF TRUTH

I believe that the facts stated in this Schedule of Past and Future Loss and Expense are true. Signed:

J. Lewis.

JUDITH EMILY LEWIS Dated 15 June 2020...