In the Court of Common Pleas of Philadelphia County First Judicial District of Pennsylvania Wrongful Death and Survival Actions Checklist Pursuant to Pa.R.C.P. No 2206 and Phila. Civ. R. *2206 Assigned Trial Division/O.C. Judge:______________________________ Civil Case/O.C. # ________________________________________________________ Caption: ___________________________________________________________________________________________________________________________ Is this case disposed except for this petition? If Yes, how was it disposed? S.D. & E. Yes Jury Trial No Non-Jury Trial Other (explain)___________________________________________________________________________________________________________________ Consolidated Cases (List All Cases IDs): ______________________________________________________________________________________________ Yes No Have any Pleadings been filed in Orphans' Court: Are the following items included in the Petition: 1. 2. 3. 4. 5. 6. 7. 8. 9. 9. 10. 11. 12. 13. Verification from Petitioner Decedent's date of death Name of personal representative and the County of appointment Decree of the Register of Wills granting Letters, and copy of the Will, if any Order appointing Guardian, if guardian appointed for minor or incapacitated person Identity of Decedent's intestate heirs by name, date of birth, relationship and address Identity of beneficiaries under Decedent's Will by name, date of birth and address Copy of the notice sent to all parties in interest and Proof of Service upon those parties in interest upon whom service was not effectuated through the Electronic Filing System Statement of final lien/claim amount from Department of Human Services, Medicare or any other entity claim or lien Counsel's reasons for approval of proposed settlement Reasons for allocation between wrongful death and survival action Reason and amount of pecuniary loss suffered by each beneficiary of Wrongful Death claim Notice to and response of the Pennsylvania Department of Revenue Itemization of costs for which reimbursement is sought Yes No Does the Order of Distribution set forth the following: 1. 2. 3. 4. 5. 6. 7. Allocation of percentage of settlement amount between Wrongful Death and Survival claims Counsel fee computed on net settlement amount for portion attributable to minor or incapacitated person Counsel Costs Final lien amount from Department of Human Services Final demand or conditional payment amount from Medicare, if final demand not available Name of settling defendants Wrongful Death Claim a. Amounts to spouse and adult children b. Amounts to minor/incapacitated person (to be placed in restricted account not to exceed FDIC insured limit, held in court approved trust, or paid to court appointed guardian) c. Amounts to parent 8. 9. Survival Claim: Payable to Administrator/Executor/rix of the Estate of the Deceased Affidavit of Compliance to be filed certifying compliance with the Order I verify the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers Date: ________________________ ________________________________________ 11-10 (Rev. 11-09-16) American LegalNet, Inc. www.FormsWorkFlow.com