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Wrongful Death And Survival Actions Checklist 11-10 - Pennsylvania
| Wrongful Death And Survival Actions Checklist Form. This is a Pennsylvania form and can be used in Orphans Court Philadelphia Local County . |
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In the Court of Common Pleas of Philadelphia County First Judicial District of Pennsylvania Joint General Court Regulation Trial Division and Orphans' Court Division No. 97-1 Wrongful Death and Survival Actions Checklist Settlement/Trial Division Judge: Caption: Is this case disposed except for this petition? If Yes, how was it disposed? ___S.D.& E. ___Yes ___Jury Trial ___No ___Non-Jury Trial (Incls. Assessment of Damages) Court Term: Number: ___Other (explain)_____________________________________________________________________________________________________ Consolidated Cases (Indicate Court Term and Number)_____________________________________________________________ Any Pleadings filed in Orphans' Court: Yes No Are the following items included in the Petition: 1. Verification from Administrator/Executor 2. If guardian of estate was appointed, is Order attached 3. Notice letter to all parties in interest is attached 4. Counsel's reasons for approval of proposed settlement 5. Reasons for the allocation between wrongful death and survival action 6. Reason and amount of pecuniary loss suffered by each beneficiary of Wrongful Death Claim 7. Petition signed by counsel 8. Department of Welfare or any other entity claim or lien 9. Does the Order of Distribution set forth the following: a. b. c. Itemization of costs for reimbursement Counsel fee computed on net settlement Wrongful Death Claim i. Amount to spouse and adult children Yes No ii. Amout to minor/incapacitated person (in restricted accounts, typically if under $350,000) iii. Amount to Guardian of minor/incapacitated person (typically if over $350,000) iv. Parent d. Survival Claim: To Administrator/Executor of the Estate of the Deceased e. Affidavit will be filed certifying compliance with the Order I verify the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers. Date: 11-10 (Rev. 01/2010) American LegalNet, Inc. www.FormsWorkFlow.com
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