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(Title of Court and Cause) SPECIAL VERDICT
We, the jury in the above entitled action, find the following special verdict on the questions submitted to us:
Question No. 1: [Was] [Were any of] the defendant[s] negligent?
Answer "yes" or "no" after the name of [the] [each] defendant. Yes No
Answer: Defendant _______________ _____ _____
[Defendant _______________ _____ _____]
[Defendant _______________ _____ _____]
If you answer Question No. 1 "no" as to [the] [each] defendant, sign and return this verdict.
If you answer Question No. 1 "yes" as to [the] [any] defendant, then answer Question No. 2 [as to such defendant].
Question No. 2: [As to each defendant that you answered "yes" to in response to Question No. 1,] was such negligence a cause of [injury] [damage] to the plaintiff?
Answer "yes" or "no" after the name of [each] such defendant. Yes No
Answer: Defendant _______________ _____ _____
[Defendant _______________ _____ _____]
[Defendant _______________ _____ _____]
If you answer Question No. 2 "no" [as to all defendants], sign and return this verdict. If you answer Question No. 2 "yes" [as to any defendant], then answer the next question.
Question No. 3: Without taking into consideration the reduction of damages due to the negligence of the plaintiff, if any, what do you find to be the total amount of damages, including economic and non-economic damages, if any, suffered by the plaintiff caused by the accident involved herein?
Answer: (a) Economic Damages $__________
(b) Non-Economic Damages $__________
TOTAL $__________
If you answer Question No. 3 "no damage", sign and return this verdict. If you answer Question No. 3 with an amount of money, answer Question No. 4.
Question No. 4: Was the plaintiff _______________ negligent?
Answer "yes" or "no".
Answer: __________
If you answer Question No. 4 "no", do not answer Question No. 5. Instead, proceed directly to Question No. 6. If you answer Question No. 4 "yes", then answer the next question.
Question No. 5: Was the negligence of the plaintiff _______________ a cause of [injury] [damage] to such plaintiff?
Answer "yes" or "no".
Answer: __________
Question No. 6: Assuming that 100% represents the total negligence [and fault] [and wrongful conduct] which was the cause of the plaintiff's [injury] [damage], what percentage of this 100% is due to the contributory negligence of the plaintiff and what percentage of this 100% is due to the [negligence] [and] [fault] [and] [wrongful conduct] of the defendant[s] [and all other persons]?
Answer: To plaintiff ______________ __________%
[To plaintiff ______________ __________%] To defendant _______________ __________% [To defendant ______________ __________%] [Other person ______________ __________%]
(Identify) [Other person ______________ __________%]
(Identify)
TOTAL __________%
[Dated: _______________
____________________
Foreperson | TOP |
(Title of Court and Cause)
SPECIAL VERDICT
We, the jury in the above entitled action, find the following special verdict on the questions submitted to us:
Question No. 1: [Was] [Were any of] the defendants negligent in the [medical] [hospital] [nursing] [diagnosis] care and treatment of plaintiff?
Answer "yes" or "no" after the name of [the] [each] defendant.
Yes No
Answer: Defendant _______________ _____ _____
[Defendant _______________ _____ _____]
[Defendant _______________ _____ _____]
If you answer Question No. 1 "no" as to [the] [each] defendant, sign and return this verdict. If you answer Question No. 1 "yes" as to [the] [any] defendant, then answer Question No. 2 [as to such defendant].
Question No. 2: [As to each defendant that you answered "yes" in response to Question No. 1,] was such negligence a cause of injury to the plaintiff?
If you answer Question No. 2 "no" [as to all defendants], sign and return this verdict. If you answer Question No. 2 "yes" [as to any defendant], then answer all of the remaining questions [as to that defendant].
Question No. 3: What amount of damage, if any, do you find was sustained by plaintiff for past pain, suffering, inconvenience, physical impairment or disfigurement, occurring from the date of such negligence to the present?
Answer: $__________
Question No. 4: What amount of damage, if any, do you find will be sustained by plaintiff for future pain, suffering, inconvenience, physical impairment or disfigurement caused by such negligence?
Answer: $__________
Question No. 5: What amount of damage, if any, do you find plaintiff sustained for the past cost of medical and hospital care and treatment resulting from such negligence?
Answer: $__________
Answer "yes" or "no" after the name of [each] such defendant.
Yes No
Answer: Defendant _______________ _____ _____
[Defendant _______________ _____ _____]
[Defendant _______________ _____ _____]
Question No. 6(a): What amount of damage, if any, do you find plaintiff will sustain for future medical, hospital, surgical and rehabilitation care resulting from such negligence?
Answer: $__________
Question No. 6(b): What amount do you find to be the present cash value of the amount stated in answer to Question 6(a)?
Answer: $__________
Question No. 7: What amount of damage, if any, do you find plaintiff has sustained for the past loss of earnings caused by such negligence?
Answer: $__________
Question No. 8(a): What amount of damage, if any, do you find plaintiff sustained for the loss of future earnings which are caused by such negligence?
Answer: $__________
Question No. 8(b): What amount do you find to be the present cash value of the amount indicated in response to Question 8(a)?
Answer: $__________
Question No. 9: Was the plaintiff __________ negligent?
Answer "yes" or "no".
Answer: __________
If you answer Question No. 9 "no", do not answer Question No. 10. Instead, proceed directly to Question No. 11. If you answer Question No. 9 "yes", then answer the next question.
Question No. 10: Was the negligence of the plaintiff __________ a cause of [injury] [damage] to such plaintiff?
Answer "yes" or "no".
Answer: __________
Question No. 11: Assuming that 100% represents the total negligence [and fault] [and wrongful conduct] which was the cause of the plaintiff's [injury] [damage], what percentage of this 100% is due to the contributory negligence of the plaintiff and what percentage of this 100% is due to the [negligence] [and] [fault] [and] [wrongful conduct] of the defendant[s] [and all other persons]?
Answer: To plaintiff ________________ __________%
To defendant ______________ __________%
[To defendant ______________ __________%]
[Other person ______________ __________%]
(Identify)
[Other person ______________ __________%]
(Identify)
TOTAL __________%
[Dated: _______________
_________________________
Foreperson | TOP |
Title of Court and Cause)
SPECIAL [VERDICT] [FINDINGS]
We, the jury in the above entitled case, find the following special verdict on the questions submitted to us:
Question No. [1] [_____]: Did the defendant[s] disclose to the plaintiff all relevant information which would enable the plaintiff to make an informed decision regarding the proposed [treatment to be rendered] [operation to be performed] by the defendant?
Answer "yes" or "no" after the name of [the] [each] defendant.
Yes No
Answer: Defendant ________________ _____ _____
[Defendant _______________ _____ _____]
[Defendant _______________ _____ _____]
If you answer Question No. [1] [_____] "yes" as to [all] defendant[s], have your foreperson sign and date this verdict. If you answer Question No. [1] [_____] "no" as to [any] defendant[s], then answer the next question.
Question No. [2] [_____]: Would a reasonably prudent person in the plaintiff's position have consented to the ____________________ (treatment/operation) if such person had been adequately informed of all the significant perils attending such ____________________? (treatment/operation)
Answer "yes" or "no".
Answer: __________
[Dated: _______________
____________________
Foreperson | TOP |
(Title of Court and Cause)
SPECIAL VERDICT
We, the jury in the above entitled action, find the following special verdict on the questions submitted to us:
Question No. 1: Was a defendant the _______________ (owner/occupant/lessor) of the premises where the plaintiff was injured?
Answer "yes" or "no" after the name of [the] [each] defendant.
Yes No
Answer: Defendant ________________ _____ _____
[Defendant _______________ _____ _____
[Defendant _______________ _____ _____
If you answer Question No. 1 "no" as to [the] [all] defendant[s], sign, date and return this verdict.
If you answer Question No. 1 "yes" as to [the] [any] defendant[s], then answer the next question as to such defendant[s].
Yes No
Question No. 2: Was such a defendant negligent in the management of the premises in question?
Answer "yes" or "no" after the name of [the] [each] defendant.
Yes No
Answer: Defendant _______________ _____ _____
[Defendant _______________ _____ _____
[Defendant _______________ _____ _____
If you answer Question No. 2 "no" as to [the] [each] defendant, sign, date and return this verdict.
If you answer Question No. 2 "yes" as to [the] [any] defendant, then answer Question No. 3.
Question No. 3: Was the negligence of the defendant in the management of the premises a cause of injury or damages to the plaintiff?
Answer "yes" or "no" after the name of [each] of such defendant.
Yes No
Answer: Defendant _______________ _____ _____
If you answer Question No. 3 "no" as to [the] [each] defendant, sign, date and return this verdict. If you answer Question No. 3 "yes" as to [the] [any] defendant then answer Question No. 4.
Question No. 4: Without taking into consideration the reduction of damages due to the negligence of the plaintiff, if any, what do you find to be the total amount of damages including economic and non-economic damages, if any, suffered by the plaintiff and caused by the accident involved herein?
Answer: (a) Economic Damages $__________
(b) Non-Economic Damages $__________
TOTAL $__________
If you answer "no damages", sign, date and return this verdict. If you answer Question No. 4 "yes" as to [the] [any] defendant and you find damages, then answer Question No. 5.
Question No. 5: Was the plaintiff negligent?
Answer "yes" or "no".
Answer: __________
[Defendant _______________ _____ _____
[Defendant _______________ _____ _____
If your answer is "no", sign, date and return this verdict. If your answer is "yes", then answer Question No. 6.
Question No. 6: Was the negligence of the plaintiff a cause of the [injury] [damages]?
Answer: "yes" or "no".
Answer: __________
If you answer Question No. 6 "no" sign, date and return this verdict. If you answer Question No. 6 "yes", answer Question No. 7.
Question No. 7: Assuming that 100% represents the total negligence [and fault] [and wrongful conduct] which was the cause of the plaintiff's [injury] [damage], what percentage of this 100% is due to the contributory negligence of the plaintiff and what percentage of this 100% is due to the [negligence] [and] [fault] [and] [wrongful conduct] of the defendant[s] [and all other persons]?
Answer: To plaintiff ______________ __________%
To defendant ____________ __________%
[To defendant ______________ __________%]
[Other person ______________ __________%]
(Identify)
[Other person ______________ __________%]
(Identify)
TOTAL __________%
[Dated: _______________
____________________ Foreperson | TOP |
(Title of Court and Cause)
SPECIAL VERDICT
Question No. 1: Did the defendant [_______________] have control of that portion of the premises where the plaintiff was injured?
Answer "yes" or "no".
Answer: __________
If you answer Question No. 1 "no", sign and return this
verdict. If you answer Question No. 1 "yes", then answer the next three questions.
Question No. 2: Did the defendant exercise reasonable care to keep the premises in a reasonably safe condition?
Answer "yes" or "no".
Answer: __________
Question No. 3: Did the defendant provide a reasonably safe place for the plaintiff to work?
Answer "yes" or "no".
Answer: __________
Question No. 4: Did the defendant warn the employees of the subcontractors of any danger that was not obvious of which the defendant knew, or which was discoverable by the defendant in the exercise of ordinary care?
Answer "yes" or "no".
Answer: __________
If you answer all Questions 2, 3 or 4 "yes", sign and return this verdict. If you answer any of Questions 2, 3 or 4 "no", then answer the next question.
Question No. 5: Was the conduct of the defendant a cause of injury to the plaintiff?
Answer "yes" or "no".
Answer: __________
(Follow with damage and contributory negligence questions, if involved.)
DATED:
___________________________
Foreperson | TOP |
SPECIAL VERDICT
We, the jury in the above entitled case, find the following Special Verdict on the questions submitted to us:
Question No. 1: Was the work which the [person] [general contractor] hired the independent [sub-]contractor to perform, likely to create a [peculiar] [special] risk of bodily harm to others unless special precautions were taken?
Answer "yes" or "no".
Answer: __________.
If you answer Question No. 1 "no", date, sign and return this verdict.
If you answer Question No. 1 "yes", then answer Question No. 2.
Question No. 2: Should a reasonable person, with the knowledge and experience of that [person] [general contractor], have recognized that the work was likely to create such a risk?
Answer "yes" or "no".
Answer: __________.
If you answer Question No. 2 "no", date, sign and return this verdict.
If you answer Question No. 2 "yes", then answer Question No. 3.
Question No. 3: Did the independent [sub-]contractor fail to exercise reasonable care to take such precautions?
Answer "yes" or "no".
Answer: __________.
If you answer Question No. 3 "no", date, sign and return this verdict.
If you answer Question No. 3 "yes", then answer Question No. 4.
Question No. 4: Was this negligence of the independent [sub-] contractor a cause of injury to plaintiff?
Answer "yes" or "no".
Answer: __________.
If you answer Question No. 4 "no", date, sign and return this verdict.
If you answer Question No. 4 "yes", then answer Question No. 5.
Question No. 5: Without taking into consideration the
reduction of damages due to the negligence of the plaintiff, if any, what do you find to be the total amount of damages suffered by the plaintiff and caused by the accident in question?
Answer: $__________.
Question No. 6: Was plaintiff negligent?
Answer "yes" or "no".
Answer: __________.
If you answer Question No. 6 "no", date, sign and return this verdict.
If you answer Question No. 6 "yes", then answer Question No. 7.
Question No. 7: Was the negligence of plaintiff a cause of injury to the plaintiff?
Answer "yes" or "no".
Answer: __________.
If you answer Question No. 7 "no", date, sign and return this verdict.
If you answer Question No. 7 "yes", then answer Question No. 8.
Question No. 8: Assuming the combined negligence of plaintiff and of the independent [sub-]contractor to be 100%, what percentage of such combined negligence is attributable to plaintiff and what percentage is attributable to the independent [sub-]contractor?
Answer: To the plaintiff _____%
To the independent [sub-]contractor _____%
TOTAL _____%
DATED: _______________
____________________
Foreperson | TOP |