Philadelphia Cnty. C.P. Municipal Court-Civil Rule 110

a. Complaints for damages as a result of injuries to persons or property, if in excess of $2,000,

shall have annexed thereto a completed Claim Fact Sheet, verified by the claimant.

b. Any party may supplement the same twenty (20) days or more prior to trial.

c. The Court may permit amendment or supplementation of the Claim Fact Sheet at any time for

good cause shown.

d. Information not included in the Claim Fact Sheet shall not be admissible at trial.

e. The Claim Fact Sheet shall be substantially in the following form:

PHILADELPHIA MUNICIPAL COURT

(CAPTION)

CLAIM FACT SHEET BODILY INJURY/PROPERTY DAMAGE

TO THE CLAIMANT: All questions must be answered. Information not supplied may not be introduced at the

time of the trial.

Note: The contents of this fact shee t and attachments may not be admissible at trial, if prohibited by the Rules of

Evidence.

1. List the names and addresses of all witnesses to this accident and/or event.

2. List and attach copies of all medical bills, narrative reports, discharge summari es, property damage and loss

of earning documents and claims.

3. Attach copies of all estimates, obtained from any source for damage to property.

4. If bodily injury is being claimed, list the date, place and any other parties involved in any earlier or later bodily

injuries and the same part(s) of your body that were injured in this claim.

5. Regarding your insurance, if known, state:

a. name of company: _____________________________________________________________________

b. address: _____________________________________________________________________________

c. policy number:________________________________________________________________________

d. claim number:_________________________________________________________________________

e. claim adjuster handling file:______________________________________________________________

.

6. List and describe photos and/or exhibits that you may introduce at the time of trial.

Understanding the false statements herein are subject to the penalties of 18 Pa.C.S. Section 4904 (relating to

unsworn falsification to authorities), I certify that the above answers are true and correct to the best of my knowledge,

information and belief.

I hereby authorize the other parties to this action or their representative(s ) to obtain my medical reports,

employment attendance and compensation records, pertaining to this specific claim, to the extent not privileged.

____________________________________

Claimant

(Instructions: This completed form should be attached to your complaint. Use additional sheets of paper if

necessary. If the claimant is a corporation, it should execute this form in accordance with the following example:

XYZ Corporation by John Jones, President. If you obtain additional information requested by th is Claim Fact Sheet,

you should immediately send the defendant(s) a supplementary Claim Fact Sheet and file a copy with the court with

an affidavit of service twenty (20) days or more prior to trial. Failure to do so may result in the exclusion of this

information at trial.)