IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON FOR THE COUNTY OF KING Regarding the Settlement of: ) ) ) ) ) ) ) No. SETTLEMENT GUARDIAN AD LITEM REPORT [Model Form] [Instructions are in brackets and printed in red. completing the Report] I. They may be omitted when SUMMARY OF RECOMMENDATIONS Minor #1 Name: _________________Gross Settlement: ____________ Net: _____________ Minor #2 Name: _________________Gross Settlement: ____________ Net: _____________ Special Issues (if any): _________________________________________________________ Plaintiff’s Attorney:______________________________ Phone:______________________ Defendant’s Attorney: ____________________________ Phone:______________________ Mediator (if any): _______________________________ Minor/Disabled Person #1: ________________________ Date of Birth: _________________ Minor/Disabled Person #2: ________________________ Date of Birth: _________________ Parent of Minor #1 Name:_________________________ Address:_____________________ Parent of Minor #1 Name:_________________________ Address:_____________________ Relative of Minor #1 Name:________________________ Address:_____________________ Parent of Minor #2 Name:_________________________ Address:_____________________ Parent of Minor #2 Name:_________________________ Address:_____________________ Relative of Minor #2 Name:________________________ Address:_____________________ Scheduled Hearing Date for Approval of Settlement: _______________________, _____. Proposed Disposition of Net Proceeds: (Check all applicable boxes) Blocked Account Structured Settlement Trust Guardianship Other SGAL Report – 06/11 – pg. 1 American LegalNet, Inc. www.FormsWorkFlow.com SETTLEMENT GUARDIAN AD LITEM A. Name of Settlement Guardian Ad Litem: _________________________________________ B. Brief Statement of Experience and Qualifications: _______________________________________________________________________ C. Relationship, if any, of SGAL with involved parents, guardians, insurers or attorneys: _______________________________________________________________________ II. DESCRIPTION OF INCIDENT AND LEGAL CLAIMS [Give a brief narrative of the occurrence. List the claims of each person arising out of it. Also be sure to list claims that can be made against each family member.] III. INVESTIGATION AND PERSONS INTERVIEWED [List the persons interviewed; their relationship to the minor, if any; and their role in the occurrence and/or care of the minor.] IV. LIABILITY ISSUES [Describe the liability issues as they pertain to the minor and other family members who were involved in the occurrence.] V. INJURIES, TREATMENT, DIAGNOSIS, AND PROGNOSIS [Enumerate each of these four components. Specifically describe the present condition of the minor and any unresolved injuries or limitations] VI. DAMAGES [List all damages that have accrued on account of the occurrence, however they may have been paid, whether by parents, insurance, PIP policies, or otherwise.] A. Special Damages: [Include special damages paid for by PIP policies and collateral sources.] B. General Damages: [Document how you, the SGAL, independently arrived at a value of the case. Consider and give weight to the settlement amount recommended by counsel for the minor. Review appropriate documentation in order to evaluate the settlement. You may also review Jury Verdicts and Arbitration Awards, or attach a copy of the SGAL Report – 06/11 – pg. 2 American LegalNet, Inc. www.FormsWorkFlow.com Plaintiff’s Demand Letter, and give a history of the demands and offers. The latter is especially helpful in a case settled at policy limits.] VII. ALL INSURANCE OR COLLATERAL SOURCES AVAILABLE TO SATISFY CLAIM [List the insurer, insured, policy limits (in all cases) and collateral sources available.] VIII. LIENS, SUBROGATION, AND REIMBURSEMENTS [Specifically include payments made, to be made, or remaining amounts available on PIP policies.] IX. IDENTIFICATION OF OTHER CLAIMS INCLUDING CLAIMS OF OTHER FAMILY MEMBERS (Include a brief description of the liability, injuries, and settlement amounts for each.) [List all claims of other family members arising out of the occurrence, whether or not they have already been settled, are being settled contemporaneously or are still at issue.] X. APPORTIONMENT (Explain the objective basis for determining the share that each injured party will receive from the whole amount the defendant will be paying on account of the occurrence.) [This paragraph applies in all cases in which more than one family member or more than one injured person has a claim or is receiving a settlement. It applies to all cases and not just “policy limits” cases, as each injured party will be receiving money out of the insured’s reserves, thus reducing the remainder available for the others. The SGAL should compare the general and special damages suffered by each claimant or recipient to assure that the minor receives a just and fair proportion of the total settlement or amounts to be paid by the insurer.] XI. PROPOSED SETTLEMENT A. Gross Settlement Amount & Payment Terms: (List the entire amounts paid, to be paid, and/or to be waived by defendant.) [This requires a listing of all consideration received or to be received on account of the occurrence. It is not merely a listing of “new money.” List each by present value – do not list the aggregate total to be paid over time by an annuity or structured settlement.] B. Proposed Arrangements for Protection of Proceeds: [Describe here what you recommend for the protection of the settlement proceeds, such as Blocked Account, Structured Settlement, Trust, Guardianship or other. If you are recommending that the Court consider more than one proposal, describe each and state which you recommend and why you favor it. Note: sometimes it is SGAL Report – 06/11 – pg. 3 American LegalNet, Inc. www.FormsWorkFlow.com beneficial to use more than one of the protective arrangements, such as a blocked account for $5,000 to pay future expenses, and buying an annuity with the balance.] C. XII. Proposed Settlement Documents: EXPENSES AND FEES A. Expenses: B. Attorney’s Fees (State the amount of the proposed fee and how it is calculated under the fee agreement.) [Discuss the fee amount in light of the stage at which the case was settled, and the work required of counsel to “build” the case. Also state whether the percentage fee was applied against subrogated damages and/or the PIP coverage.] XIII. DISPOSITION OF NET PROCEEDS A. Proposed Settlement: Minor # 1 Minor #2 $_____________ $_____________ Costs: $_____________ $_____________ Attorney Fees: $_____________ $_____________ Subrogation and Liens: $_____________ $_____________ settlement): $_____________ $_____________ Other: $_____________ $_____________ Net Proceeds for Disposition: $_____________ $_____________ $_____________ $____________ Gross Settlement: Less: SGAL fee (if paid from If SGAL fee is to be paid separately as a cost by the insurer or third party: B. Disposition of Net Proceeds (State the proposed plan of disposition of funds and why it is preferred to other alternatives.) [Be sure to discuss the alternatives with the family of the injured minor, as the eventual decision will be a combination of their preferences and your recommendations, all considered in the court’s sound exercise of discretion.] C. Alternative Proposal(s) If Any: SGAL Report – 06/11 – pg. 4 American LegalNet, Inc. www.FormsWorkFlow.com XIV. SETTLEMENT GUARDIAN AD LITEM FEES Fee Request: $ _________________ Proposed to be paid by: Insurance Company (name)____________________________ Parent Defendant Settlement Funds Other: _________________ See accompanying Declaration of Fees and Costs filed herewith for a statement of time spent, expenditures made, and fees and costs requested by the Settlement Guardian ad Litem. XV. WHO SHOULD BE PRESENT AT THE HEARING TO APPROVE SETTLEMENT [List those who should be present at the hearing; and those who need not be.] XVI. SETTLEMENT APPROVAL IN OTHER JURISDICTIONS [List the name and case number of related cases filed, pending, or resolved in other courts or jurisdictions. This may include a prior filing of the matter in this or another county; a probate; a wrongful death action; or a matter filed in Federal District Court.] XVII. CONCLUSION I certify or declare under penalty of perjury according to the laws of the State of Washington that the foregoing statements are true and correct. ___________________________________ (Date Report Signed) _____________________________________ Signature of Settlement Guardian ad Litem ___________________________________ (City or County Where Report Signed) _____________________________________ Printed Name of Settlement Guardian ad Litem _____________________________________ Address _____________________________________ City/State/Zip _____________________________________ Telephone / Fax Number _____________________________________ E-mail Address SGAL Report – 06/11 – pg. 5 American LegalNet, Inc. www.FormsWorkFlow.com