Form 2.5	Statement of claim—death or personal injury other than motor vehicle or employment-related
Court Procedures Rules 2006
(see r 50 (Originating claim—content etc), r 303 (Third-party notice—content etc))
In the *[Supreme/Magistrates] Court of the Australian Capital Territory

No *[SC/MC]		of (year) (Court to complete)

(name)
Plaintiff

(name)
Defendant

The plaintiff claims damages for *[death/personal injury] in relation to the defendant’s negligence as follows:
1	Time, date, place, circumstances and acts or omissions making up the negligence: 
	(a)	(time and date)
	(b)	(where negligence happened or death/injury suffered)
	(c)	(circumstances and acts or omissions).
2	Particulars of negligence: 
(particulars).
3	Injuries and disabilities suffered by the plaintiff: 
(particulars).
4	Health professionals who have treated the plaintiff for injuries/disabilities: 
(name and address of each health professional).
5	Particulars of loss/damage: 
	(a)	(injuries)
	(b)	(disabilities).
*6	If a claim is made for economic loss: 
	(a)	(particulars of past economic loss);
	(b)	(particulars of future economic loss).
*7	Particulars of employment: 
(a)	(name and address of each of plaintiff’s employers during a reasonable period before act or omission making up negligence);
(b)	(name and address of each of plaintiff’s employers since act or omission making up negligence).
*8	Other material facts relied on in support of claim:
(particulars).
Date:
(signature of plaintiff or plaintiff’s solicitor)
(name of plaintiff or plaintiff’s solicitor)

*omit if, or whichever is, inapplicable