Form 3	Statement of claim—motor vehicle death or personal injury 
Court Procedures Rules 2006
(see r 52 (Originating claim—statement of claim for motor vehicle death and personal injury claims) and r 305 (Third-party notice—statement of claim for certain personal injury claims))
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 negligent use of a motor vehicle (the accident).
Details of the claim are as follows:
	time, date, place, and circumstances of the accident (including, if possible, registration details of all vehicles involved):
	precise particulars of the defendant’s negligence:
*(if a claim is made for personal injury)
	injuries and disabilities suffered by the plaintiff:
	the name of each health professional who has treated the plaintiff for the injuries and disabilities:

*(if a claim is made for economic loss)
	nature of claims for past or future 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:
*(other material facts relied on in support of claim)

Date:
(signature of plaintiff or plaintiff’s solicitor):
(name of plaintiff or plaintiff’s solicitor)

*omit if, or whichever is, inapplicable