Uniform Arbitration Statement Of Facts {10505}

UNIFORM ARBITRATION STATEMENT OF FACTS (Use for all but Commercial Cases) Caption: (Please include Consolidated Case Docket No. If applicable) (Verbal Threshold) Yes No Docket No: Arbitration Date/Time: Auto: P.I. Party Represented: I. Briefly describe the accident/incident occurred. (Please attach police report or expert liability reports): II. Liability (Please attach expert reports) III. Damages A. Non-Economic Losses l. List injuries (Please attach only hospital discharge summary and/or narrative reports/IME) 2. List objective testing and dates. 3. List current treatments and complaints. Revised 7/13/2000, CN 10505-English page 1 of 2 B. Economic Losses (List all out of pocket expenses) 1. Itemized list of all medical bills Treating Doctor/Hospital/Other Amount Total Amount Unpaid Bills 2. Net Wage Loss (List all out of pocket expenses) 3. Miscellaneous expense (Please itemize) Amount C. Workers' Compensation and Other Liens (please list) IV. Other issues you contend that the arbitrator should consider: I certify this information to be complete and accurate and that copies of this statement have been timely served on all adversaries pursuant to R. 4:21A-4. Signature of Attorney or Pro Se Litigant Date (Please print or type name) Attorney for: PLEASE DO NOT SEND COPIES OF BILLS, DEPOSITION TRANSCRIPTS, INTERROGATORIES, OR COPIES OF PHOTOGRAPHS. HOWEVER, BE PREPARED TO BRING COPIES OF RELEVANT EVIDENCE. NOTE: Information provided on this form can not be used for evidentiary purposes in any trial of this matter page 2 of 2 Revised 7/13/2000, CN 10505-English