PRE-TRIAL STATEMENT PRESENT TO BAILIFF FOR JUDGE JOHN O'DONNELL AT TIME OF PRE-TRIAL CASE NO. ____________________ PRE-TRIAL DATE _____________________ ______________________________VS.____________________________________ 1. Description of case: ___________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 2. Description of injuries or damages: _______________________________________ ______________________________________________________________________ ______________________________________________________________________ 3. Damages: (Medical expenses, lost wages, property damages, etc.) _________________________________ _________________________________ _________________________________ TOTAL 4. Report on status of the following: A. Depositions B. Defense Medical Examinations C. Exchange of Witness Reports 5. Real party in interest ___________________________ Name of Carrier 6. STIPULATIONS: Use reverse side 7. Lowest Demand ________________ Highest Offer __________________ ________________________________ Name of Representative __________________________ __________________________ __________________________ $____________________ $____________________ $____________________ $____________________ 8. Waive Jury ____________________ Refer to Arbitration ______________ Mediation __________________ Counsel stipulate under provision of Rule 11 to the accuracy of the representations made above. ___________________________________________ Counsel for Plaintiff/Defendant (type name below) American LegalNet, Inc. www.FormsWorkFlow.com