STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO ) ) ) Plaintiff (s) ) ) ) ) ) ) vs. No. INITIAL PRETRIAL DATE: Defendant (s) PRETRIAL MEMORANDUM The information required in this Memorandum should be full, complete, typewritten, and in triplicate and mailed or delivered to all attorneys of record and filed with the Winnebago County Circuit Clerk's Office not less than seven (7) days before the date of the pretrial conference. 1. Plaintiff's law firm: Lead attorney: Address: Phone: 2. Defendant No. 1: Law firm: Lead attorney: Address: Phone: Defendant No.2: Law firm: Lead attorney: Address: Phone: Defendant No.3: Law firm: Lead attorney: Address: Phone: 3. Plaintiff's Name 4. Plaintiff's Age & Marital Status: 5. Plaintiff's Occupation: 6. Date, hour and place of occurrence: A-8 APPENDIX H 04/95 2002 © American LegalNet, Inc. APPENDIX H - Continued 7. Statement of facts: 8. Plaintiff's theory of liability: 9. Defendant's theory of liability: 10. Plaintiff's description of injuries: 11. Plaintiff's present complaints if any: 12. Third-party claims, if any: DAMAGES MEDICAL EXPENSES: DATES: NAMES: Hospital ER and outpatient Inpatient Attending Physician(s): Consulting Physician(s): X-ray Laboratory: Physical Therapy: Medical Aids (describe): Future medical: Ambulance: Other: AMOUNT: $ $ $ $ $ $ $ $ $ $ $ $ Medical Sub-total: $ A-8.1 APPENDIX H 04/95-22002 © American LegalNet, Inc. APPENDIX H - Continued LOSS OF EARNINGS: From to employed at $ From to employed at $ Future loss of earnings: Earnings Sub-total: $ PERMANENT DISABILITY, if any: MISCELLANEOUS DAMAGES: $ $ $ Miscellaneous Sub-Total: TOTAL SPECIAL DAMAGES: Plaintiff's Demand: $ Defendant's No. 2 Offer: $ $ Defendant's No. 1 Offer: $ $ A-8.2 APPENDIX H -3- 04/95 2002 © American LegalNet, Inc.