45.04.C Wrongful Death Act--Survival Act--Verdict Form C--Contributory Fault of Beneficiary and Decedent or Beneficiary Only 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 $_____________ $_____________ $_____________ $_____________ $_____________ Yes ___ Yes ___ No ___ No ___ Second: Assuming that 100% represents the total combined [negligence] [fault] [responsibility] of all [persons] [or entities] whose [negligence] [fault] [responsibility] proximately caused the death of [name of decedent], we find the percentage of [negligence] [fault] [responsibility] attributable to each as follows: (a) (b) (c) (d) [name of decedent] decedent [name of beneficiary] beneficiary [Name of defendant 1] Defendant 1 [Name of defendant 2] Defendant 2 _____% _____% _____% _____% _________________________________ Foreperson _________________________________ _________________________________ __________________________________ __________________________________ __________________________________ _________________________________ _________________________________ _________________________________ __________________________________ __________________________________ __________________________________