45.04.A Wrongful Death Act--Survival Act--Verdict Form A-- No Contributory Fault We, the jury, find for the estate of [name of decedent], deceased, and against the following defendants: [name of defendant 1] Defendant 1 [name of defendant 2] Defendant 2 We further find the following: First: We find that the total amount of damages suffered by the Estate of [name of decedent], deceased, is $_____________, itemized as follows: [Loss of money, goods and services]: [Grief, sorrow and mental suffering]: [Loss of society] and [loss of sexual relations]: [Other damages: insert from 30.04, 30.04.01, 30.05, 30.05.01, 30.06, 30.07, 30.09 or as applicable] PLAINTIFF'S TOTAL DAMAGES _________________________________ Foreperson _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ $_____________ $_____________ $_____________ $_____________ $_____________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Yes ___ Yes ___ No ___ No ___