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Settlement Conference Memorandum Form. This is a Illinois form and can be use in Dupage Local County.
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Tags: Settlement Conference Memorandum, Illinois Local County, Dupage
IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT
DU PAGE COUNTY, ILLINOIS
SETTLEMENT CONFERENCE MEMORANDUM
)
)
)
)
)
vs.
No.
Date of Occ.: _______________________
PL Atty.:
_______________________
Loc. of Occ.: _______________________
Phone:
_______________________
_______________________
DF Atty.:
_______________________
DF Atty.:
_______________________
#1 Phone:
_______________________
#2 Phone:
_______________________
PL’s Theory of Liability: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Damages of Plaintiff (Name): ________________________________________ (Age) ______
Description of Injuries: _________________________________________________________
Plaintiff’s Present Complaints, if any: ______________________________________________
Medical Expenses:
Dates
Names
Hospital Emergency Room On_______________ ______________________
Hospital Confinement
(_____to_____)
______________________
Treating Doctor
(_____to_____)
______________________
Treating Doctor
(_____to_____)
______________________
Consulting Doctor
(_____to_____)
______________________
Examining Doctor
(_____to_____)
______________________
X-Ray Laboratory
(_____to_____)
______________________
Physical Therapy
(_____to_____)
______________________
Med. Aids (Described)
(_____to_____)
______________________
Future medical and lost time, if any: __________________________________
TOTAL
Loss of Earnings:
From _____to_____ employed at _________________________________
From _____to_____ employed at _________________________________
Permanent Disability, if any: ______________________________________
TOTAL
Miscellaneous Damages:
_______________________________________________________________
_______________________________________________________________
TOTAL
PL Demand: $__________
DF No. 1 Offer: $__________
Charges
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
DF No. 2 Offer: $________
Judge’s Recommendation: $__________
Appendix of Civil Forms
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