Petition To Settle Wrongful Death And Survival Actions Page 3
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105-19-16
_________________________________________________________________________
(If additional space is needed, please continue on a separate page).
10.
Counsel is of the professional opinion that the proposed settlement is reasonable due
to the following (state the reasons why in the professional opinion of counsel the settlement is
proper):
______________________________________________________________________________
______________________________________________________________________________
(If additional space is needed, please continue on separate page).
11.
Petitioner is of the opinion that the proposed settlement is reasonable.
12.
Counsel has incurred the following expenses for which reimbursement is sought (Please set
forth in detail):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
(If additional space is needed, please continue on separate page).
13.
Counsel requests counsel fees in the amount of $___________ which
represents _____% of the net proceeds of the settlement.
14.
Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs
and attorneys fees) as follows:
a.
Wrongful Death Claim $_________________
b.
Survival Claim
$_________________
15.
The reason for the requested allocation are as follows:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
(If additional space is needed, please continue on a separate page).
16.
Pursuant to the Wrongful Death Statute (42 Pa. C.S. §8301), the beneficiaries of the Wrongful
Death Claim, and the proportion of their interest, are as follows:
NAME
AMOUNT DUE
__________________________________
________________________
__________________________________
________________________
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