Form
14 (version 2)
UCPR 15.12
UCPR 15.12
STATEMENT OF PARTICULARS
PERSONAL INJURY PROCEEDINGS
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COURT DETAILS
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Court
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#Division
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#List
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Registry
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Case number
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TITLE OF PROCEEDINGS
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[First] plaintiff
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[name]
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#Second plaintiff #Number of
plaintiffs (if more than two)
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[First] defendant
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[name]
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#Second defendant #Number of
defendants (if more than two)
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FILING DETAILS
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Filed for
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[name] [role of party eg
plaintiff]
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#Filed in relation to
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[eg
plaintiff's claim, (number) cross-claim]
[include
only if form to be eFiled]
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#Legal representative
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[solicitor on record] [firm]
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#Legal representative reference
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[reference number]
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Contact name and telephone
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[name] [telephone]
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Contact email
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[email address]
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PARTICULARS OF INJURIES
RECEIVED
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PARTICULARS OF CONTINUING
DISABILITIES
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PARTICULARS OF OUT-OF-POCKET
EXPENSES
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#PARTICULARS OF CLAIM FOR
DOMESTIC ASSISTANCE OR ATTENDANT CARE
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#PARTICULARS OF LOSS OF
INCOME
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#PARTICULARS OF LOSS OF
EARNING CAPACITY AND FUTURE ECONOMIC LOSS
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#PARTICULARS OF ANY OTHER
AMOUNTS CLAIMED
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LIST OF DOCUMENTS SERVED
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[Include,
hospital, medical and experts' reports, hospital and medical
accounts, workers' compensation accounts, employment records and all
other documents in support of the particulars given above and
referred to in UCPR 15.12. You should include a statement of reasons
as to why any document or part of document which cannot be served
with this statement is not served.]
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SIGNATURE
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#Signature
of legal representative
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#Signature
of or on behalf of party if not legally represented
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Capacity
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[eg
solicitor, authorised officer, role of party]
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Date of
signature
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