Ill. Pattern Jury Instr. (Civil) 45.04C

Beneficiary and Decedent or Beneficiary Only

We, the jury, find for the Estate of ____, deceased, and against the following defendants:

____________________ Yes _____ No _____

Defendant 1

____________________ Yes _____ No _____

Defendant 2

We further find the following:

First: We find that the total amount of damages suffered by the Estate of ___________, deceased,

is $____________________, itemized as follows:

[Loss of money, benefits, goods and services]: $_______________

[Grief, sorrow and mental suffering]: $_______________

[Loss of society] and [loss of sexual relations]: $_______________

[(Other damages: insert from 30.04, 30.04.01,

30.05, 30.05.01, 30.06, 30.07, 30.09

or as applicable)] $_______________

PLAINTIFF'S TOTAL DAMAGES $_______________

Second: Assuming that 100% represents the total combined [negligence] [fault] [responsibility]

of all [persons] [or entities] whose [negligence] [fault] [responsibility] proximately caused the

death of [decedent], we find the percentage of [negligence] [fault] [responsibility] attributable to

each as follows:

a) ___________________ _____%

Decedent

b) ___________________ _____%

Beneficiary

c) ___________________ _____%

Defendant 1

d) ___________________ _____%

Defendant 2

_____________________________ ___________________________

Foreperson

_____________________________ ___________________________

Add additional lines for juror signatures.

Verdict Form, Notes and Comment approved May 2014.