Form 2.3	Statement of claim—motor vehicle death or personal injury
Court Procedures Rules 2006
(see r 50 (Originating claim—content etc), r 52 (Originating claim—statement of claim for motor vehicle death and personal injury claims) and 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 negligent use of a motor vehicle (the accident) as follows:
1	Time, date, place and circumstances of the accident (including, if possible, registration details of all vehicles involved):
	(a)	(time and date)
	(b)	(place)
	(c)	(details of vehicles’ registration and drivers)
	(d)	(circumstances)
2	Precise particulars of the defendant’s negligence:
(particulars)
3	Injuries and disabilities suffered by the plaintiff:
	(a)	(injuries)
	(b)	(disabilities)
4	Health professionals who have treated the plaintiff for the injuries and disabilities:
(name and address of each health professional)
*5	Claims for economic loss: 
	(a)	(particulars of past economic loss)
	(b)	(particulars of future economic loss)
*6	Particulars of employment: 
(a)	(name and address of each of plaintiff’s employers during a reasonable period before accident)
(b)	(name and address of each of plaintiff’s employers since accident)
*7	Other material facts relied on in support of claim:
(particulars)

*Acknowledgement that plaintiff has filed a copy of mandatory final offer
(complete this section unless the Court has given leave to commence proceedings under the Road Transport (Third-Party Insurance) Act 2008, section 150 (Need for urgent proceeding))

A mandatory final offer was made under the Road Transport (Third-Party Insurance) Act 2008, section 141 on (date). The offer remained open until (date). A sealed envelope containing a copy of the offer is filed with this claim.

Date:
(signature of plaintiff or plaintiff’s solicitor)
(name of plaintiff or plaintiff’s solicitor)
*omit if, or whichever is, inapplicable