IN THE SUPERIOR COURT OF THE STATE OF DELAWARE COUNTY: NEW CASTLE KENT SUSSEX ) Plaintiff(s) ) ) ) C.A. No.: ________________________________ ) v. ) ) ) Defendant(s) ) ) NEUTRAL ASSESSMENT HEARING STATEMENT The Neutral Assessment Statement is a confidenti al document intended to assist the neutral assessor prepare for the neutral assessment Hearing. It should be submitted to the neutral assessor only. 1) State the facts of the case; and if applicable the nature of any equitable relief being sought. 2) With respect to the issue of liability, please complete the following: a) Does this case involve and affirmative defense? If yes, describe. b) State any facts that will bar or diminish any recovery by the plaintiff. 3) Provide a concise statement of any other claims (cross-claims, counter-claims or third party claims) and respective defenses thereto: >>>> 2 4) If this is a personal injury or wrongful death action, each plaintiff shall complete the following: a) Nature and extent of injuries and whether they are permanent. b) Nature of any surgical procedures recommended, scheduled, or performed. c) Total medical expenses to date: $ _______________ ___________ d) Future medical expenses: $ __________________________ e) Loss of earnings to date - Amount: $ __________________________ For what period: __________________________ f) Future loss of earnings: Estimated Amount: $ __________________________ For what period: __________________________ g) Other special damages (specify nature and amount): $ __________________________ h) General damages (specify nature and amount): $ __________________________ 1. Punitive damages: $ ___________________________ 5. If this is not a personal injury case, each plaintiff shall state the following with respect to each alleged item of damages: Identify each item of damage and state whet her it is supported by documentary evidence (type and amount): >>>> 3 6. Please list the amount of counsel fees incurred to date and out-of-pocket costs. (Please note if fees are subject to contingent fee agreement). 7. Please note any liens (e.g., workmans compensation, medical providers, etc.) which will be asserted against any recovery obtained in this case (list any lien holder and amount). 8. If you are a plaintiff in this action, state the terms of your demands in order to settle this matter: 9. If you are a defendant in this action, state the terms of offer in order to settle this matter: Dated: ________________ __________________________________________ A ttorneys Signature __________________________________________ A ttorneys Name (Please Print) Attorney For: _____________________________ Revised 8.21.03