Supreme Court Rules 1937—Form 1.4
(see o 2 r 12)
Motor vehicle personal injury claim statement to accompany originating application
In the Supreme Court of the Australian Capital Territory

No		of (year)

(name/s)
Plaintiff[s]*

(name/s)
Defendant[s]*
In an originating application dated [date], the plaintiff claims damages for death or bodily injury in relation to the use of a motor vehicle.
Details of that claim are as follows:
•	Time, date, place and circumstances of the use of the motor vehicle (including, where possible, registration details of all vehicles involved):
•	Precise particulars of the defendant’s negligence
•	Injuries and disabilities suffered by the plaintiff1
•	Plaintiff’s health professionals2
•	Nature of claims for past or future economic loss*
If a claim is made for economic loss—the name and address of each employer of the plaintiff during a reasonable period before and since the use of the motor vehicle:*
Date:
Signature of plaintiff*/plaintiff’s solicitor*:
*Strike out where inapplicable.
Note 1	See the Supreme Court Rules 1937, order 2 rule 12 (c).
Note 2	See the Supreme Court Rules 1937, order 2 rule 12 (d).

Endnote
1	This form was originally in the Supreme Court Rules 1937.  Under the Court Procedures Act 2004 A2004-59, pt 8, the form became a form approved under that Act. 

©  Australian Capital Territory 2005