STATE OF ILLINOIS ) ) SS COUNTY OF _________________ ) IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT ____________ COUNTY, ILLINOIS ) ) ) ___________________________________ ) MINOR ESTATE OF NO. __________________ PETITION FOR LEAVE TO SETTLE CAUSE OF ACTION FOR MINOR PLAINTIFF Now comes your petitioner, ______________________________, and represents to and petitions this Honorable Court as follows: 1. That your petitioner is the parent and next friend of ___________________________, a minor, who was born on the ________________ day of ____________________, ______. 2. That the minor plaintiff received personal injuries and makes claim against _____________________________ (here insert name and address of person or entity against whom cause of action is accrued) by reason of an occurrence on the ________ day of _____________, ____, to wit (here give brief description of occurrence giving rise to cause of action). 3. At the time of the aforesaid occurrence a policy or policies of liability insurance were in effect providing coverage as follows: (here insert name of insurance company and the monetary limits of the liability coverage in effect for any of the persons or entities against whom claim is being made). 4. As a result of aforesaid occurrence, the minor plaintiff received injuries as follows: (here insert brief description of the injuries sustained by the minor). Expenses were incurred on behalf of the minor plaintiff as follows: (here insert list of hospital and medical expenses incurred). 5. Attached to this Petition is a current medical certificate or letter executed by the minor plaintiff's attending physician stating nature and extent of the injuries sustained by the minor plaintiff and the medical prognosis for the minor plaintiff. Rule 14.21 171-303P Rev. 10/01 Page 1 of 3 2002 © American LegalNet, Inc. 6. An offer of settlement of the claim for personal injuries of the minor plaintiff has been made in the amount of ________________________________ DOLLARS. 7. Your petitioner has retained the legal services of ________________________ (here insert attorney or law firm) to represent the minor plaintiff in the aforesaid claim for personal injuries and the attorney retained believes that the settlement offer as aforesaid is a fair and reasonable settlement of the claim for personal injuries to the minor plaintiff and that it is in the best interests of the minor plaintiff that the settlement offer be accepted and that the person or entity against whom the claim for damages has been made be released from any and all further liability. 8. Your petitioner has agreed to pay attorney's fees to _____________________ (here insert attorney or law firm retained) in the amount of ________________________ (here insert fee arrangement) of any settlement plus costs incurred for investigation purposes. 9. Investigation costs have been incurred in the amount of __________________ DOLLARS which are itemized as follows: (here itemize all investigation costs and court costs). WHEREFORE, your petitioner prays that an Order be entered: a. Permitting your petitioner to accept the settlement offer in the amount of __________________ DOLLARS in consideration of your petitioner executing and delivering a release of any and all claims. b. Directing the retained attorney to be paid the sum of ________________ DOLLARS for attorney's fees and further the sum of __________________ DOLLARS for reimbursement of this amount paid out for investigation costs and court costs. c. Appointing a guardian of the Estate of ____________________, a minor. ______________________________ __________________, Parent and Next Friend of ________________________, a minor. Rule 14.21 171-303P Rev. 10/01 Page 2 of 3 2002 © American LegalNet, Inc. STATE OF ILLINOIS COUNT OF ) ) ) SS I, ___________________________________, first being duly sworn on oath, do state that the statements contained in the above Petition are true and correct. _________________________________________ ___________________________, Parent and Next Friend of ________________________________, a minor. SUBSCRIBED and SWORN to before me this __________ day of _______________, _____. _____________________________________ Notary Public STATE OF ILLINOIS COUNTY OF ) ) ) SS I, __________________________________________, being first duly sworn on oath, state that as one of the attorneys for _______________________________, a minor, I have examined the facts and circumstances surrounding the claim for personal injuries to the minor plaintiff and the law covering such facts and that in my opinion the proposed settlement set forth in the foregoing Petition is just and proper, and I therefore recommend that the settlement be accepted. _________________________________________ SUBSCRIBED and SWORN to before me this _______ day of _________________, _____. __________________________________ Notary Public Rule 14.21 171-303P Rev. 10/01 Page 3 of 3 2002 © American LegalNet, Inc.