IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY FIRST JUDICIAL DISTRICT OF PENNSYLVANIA CIVIL TRIAL DIVISION : : : : : CASE MANAGEMENT CONFERENCE MEMORANDUM Filing party: By: , Esq. Counsel’s address and telephone number (IMPORTANT) Part A (to be completed in personal injury cases) 1. Date of accident or occurrence: 1(a). Age of Plaintiff(s): 2. Most serious injuries sustained: 3. Is there any permanent injury claimed? Yes No 5. Is medical treatment continuing? Yes No 6. Has there been an inpatient hospitalization? Yes No If yes, indicate the type of permanent injury: 4. Dates of medical treatment: This form shall be presented to the Case Manager and copies served upon all parties at the Case Management Conference by counsel prepared to discuss its contents. 01-105 (Rev. 10/99) (1) American LegalNet, Inc. www.USCourtForms.com 7. Has there been any surgery? Yes No If yes, indicate the type of surgery: 8. Approximate medical bills to date: $ Approximate medical bills recoverable in this case: $ 9. Are there any existing liens (Workers Compensation, DPW, Medical, etc.)? Yes No If yes, what type and approximate amount? 10. Time lost from work: 11. Approximate past lost wages: 12. Is there a claim for future lost earning capacity? Yes No Yes No Yes No If yes, approximate future lost earning capacity: 13. Are there any related cases or claims pending? If so, list caption(s) or other appropriate identifier: 14. Do you anticipate joining additional parties? 15. Plaintiff’s factual position as to liability: 16. Defense factual position as to liability: 17. Defense position as to causation of injuries alleged: 18. Identify all applicable insurance coverage: Defendant Insurance Carrier Are there issues as to the applicability of the above insurance coverage: 19. Demand: $ Coverage Limits Yes No Offer: $ 01-105 (Rev. 10/99) (2) American LegalNet, Inc. www.USCourtForms.com Part B (to be completed in all cases other than personal injury) 1. Date of contract of transaction: 2. Is there a writing? Yes Yes If yes, is there an allegation that the writing does not contain the entire agreement of the parties? 3. Is the Uniform Commercial Code applicable to this case? No No Yes No 4. Describe the nature of the conduct alleged as giving rise to the cause of action: 5. State the amount of damages claimed by Plaintiff: (a) Direct (b) Consequential (c) Other (specify) 6. Defense position as to alleged nature of conduct giving rise to cause of action and any counterclaim: 7. If there is a counterclaim, state the amount of damages sought: (a) Direct (b) Consequential (c) Other (specify) 8. Identify all applicable insurance coverage: Defendant 9. Demand: $ Insurance Carrier Coverage Limits Offer: $ 01-105 (Rev. 10/99) (3) American LegalNet, Inc. www.USCourtForms.com