IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY FIRST JUDICIAL DISTRICT OF PENNSYLVANIA CIVIL TRIAL DIVISION : : : : :
CASE MANAGEMENT CONFERENCE MEMORANDUM
Filing party: By: , Esq.
Counsel's address and telephone number (IMPORTANT)
Part A
(to be completed in personal injury cases)
1. Date of accident or occurrence: 1(a). Age of Plaintiff(s): 2. Most serious injuries sustained:
3. Is there any permanent injury claimed? If yes, indicate the type of permanent injury:
Yes
No
4. Dates of medical treatment: 5. Is medical treatment continuing? 6. Has there been an inpatient hospitalization? Yes Yes No No
This form shall be presented to the Case Manager and copies served upon all parties at the Case Management Conference by counsel prepared to discuss its contents.
01-105 (Rev. 10/99) (1)
7. Has there been any surgery? If yes, indicate the type of surgery: 8. Approximate medical bills to date: $ Approximate medical bills recoverable in this case: $
Yes
No
9. Are there any existing liens (Workers Compensation, DPW, Medical, etc.)? If yes, what type and approximate amount? 10. Time lost from work: 11. Approximate past lost wages: 12. Is there a claim for future lost earning capacity? If yes, approximate future lost earning capacity: 13. Are there any related cases or claims pending? If so, list caption(s) or other appropriate identifier: Yes No Yes No
Yes
No
14. Do you anticipate joining additional parties? 15. Plaintiff's factual position as to liability:
Yes
No
16. Defense factual position as to liability:
17. Defense position as to causation of injuries alleged: 18. Identify all applicable insurance coverage: Defendant Insurance Carrier Coverage Limits
Are there issues as to the applicability of the above insurance coverage: 19. Demand: $
01-105 (Rev. 10/99) (2)
Yes Offer: $
No
Part B
(to be completed in all cases other than personal injury)
1. Date of contract of transaction: 2. Is there a writing? If yes, is there an allegation that the writing does not contain the entire agreement of the parties? 3. Is the Uniform Commercial Code applicable to this case? Yes No
Yes Yes
No No
4. Describe the nature of the conduct alleged as giving rise to the cause of action:
5. State the amount of damages claimed by Plaintiff: (a) Direct (b) Consequential (c) Other (specify) 6. Defense position as to alleged nature of conduct giving rise to cause of action and any counterclaim:
7. If there is a counterclaim, state the amount of damages sought: (a) Direct (b) Consequential (c) Other (specify) 8. Identify all applicable insurance coverage: Defendant Insurance Carrier Coverage Limits
9. Demand: $
01-105 (Rev. 10/99) (3)
Offer: $