IN THE ____________ COURT OF ___________ COUNTY
IN AND FOR THE STATE OF ______________

[ENTER NAME],
Plaintiff
vs.
[ENTER NAME],
Defendant

Case No. ______________
Honorable: _____________

COMPLAINT

1. COMES NOW Plaintiff [ENTER NAME], with this complaint against the
Defendant [ENTER NAME]. Plaintiff’s action seeks to hold Defendant liable for an accident
that was caused by Defendant’s vehicle. Plaintiff therefore seeks damages against the
Defendant. In support of this Complaint, Plaintiff states as follows:

PARTIES

2. Plaintiff, [ENTER NAME], is an individual of address [ENTER ADDRESS].
3. Defendant, [ENTER NAME], is an individual of address [ENTER
ADDRESS].

JURISDICITON AND VENUE

4. This Court has subject matter jurisdiction pursuant to _____________,
because ______________.
5. Venue is proper in this Court under ___________ as Plaintiff and/or
Defendant is subject to personal jurisdiction in this state. Plaintiff and/or Defendant lives
within the jurisdiction of this Court. Besides, a substantial part of the acts and omissions

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forming the basis of these claims occurred in this County and arose from the actions or
inactions of the Defendant.

FACTS

6. On or about [ENTER DATE], the Defendant’s vehicle was involved in an
accident with the Plaintiff’s vehicle.
7. The individual operating the Defendant’ vehicle was at fault since [ENTER
FACTS].
8. As a result of the accident, the Plaintiff’s vehicle was damaged. The Plaintiff’s
cell phone was also damaged.
9. After the accident, the Defendant’s insurance company refused to compensate
the Plaintiff for the damages that Plaintiff suffered. Accordingly, Plaintiff had to get
compensation from his insurance company. However, the Plaintiff’s insurance company did
not compensate Plaintiff for his damaged phone, and for a shelf that was inside Plaintiff’s
vehicle, which was also damaged in the accident.
10. The Defendant, as the owner of the vehicle, should compensate the Plaintiff
for the damages incurred by the Plaintiff in the accident.
CLAIMS FOR RELIEF
COUNT 1
Negligence

11. Plaintiffs hereby incorporate by reference all the allegations contained in all
the preceding paragraphs of this complaint as though fully stated herein.
12. Road users have the obligation to keep other members of the public safe to the
best of their abilities. Accordingly, the person operating the Defendant’s vehicle on the day of
the accident, as a road user, had a duty of care towards other road users, including the
Plaintiff.

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13. However, the said individual failed to use reasonable care when using the
road. The Defendant breached the duty by [ENTER FACT].
14. Had it not been for the individual’s negligent driving, the accident would not
have occurred. It follows; the accident and the consequent damages were proximately and/or
directly caused by the individual’s negligence, whose conduct therefore led to the Plaintiff’s
losses.
WHEREFORE Plaintiff demands judgment for damages against Defendant as the
owner of the automobile, interests, costs, and such other relief as the Court deems proper and
just.

PRAYER FOR RELIEF

WHEREFORE, the Plaintiff is entitled to damages from the Defendant. The Plaintiffs
hereby pray that judgment be entered in their favor and against the Defendant and the
following order be issued:
i. Finding the Defendant liable for the accident and the losses and/or damages
incurred by Plaintiff, since Defendant is the owner of the vehicle that caused the
accident.
ii. Actual damages, in an amount to be established by the Court, for the blameworthy
conduct that caused the accident as alleged herein;
iii. Interest as provided by law;
iv. An award of fees and costs;
v. Such other relief as the Court deems just and proper.

Respectfully submitted:

Dated: __________

______________________________
[ENTER NAME]
.
Pro se

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CERTIFICATE OF SERVICE

I, [ENTER NAME], hereby certify that on [ENTER DATE], a copy of the foregoing
Complaint has been sent to the Defendant in the following address:

[ENTER DEFENDANT’S ADDRESS]

______________________________
[ENTER NAME]
Pro se

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