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1 Client Ref. No. Please use the Notes for Guidance when completing this form. Note 1. Note 2. Note 3. Note 4. Note 5. Note 6. Note 7. Note 8. IN THE Between PARTICULARS OF CLAIM - OCCUPIERS LIABILITY AND Particulars Claim No. 1. The Defendant was at all material times the occupier of premises known as ("the premises") being premises to which the Occupiers Liability Act 1957 Act") applied Claimant Defendant 4. The Claimant's said accident occurred as a result of the negligence and/or breach of statutory duty on the part of the Defendant, its servants or agents. (i) failing to ensure that the Claimant would be reasonably safe in using the said premises for the purposes for which he/she was invited or permitted to be there; ("the 2. The Claimant was at all material times a visitor to the said premises within the meaning of the said Act. pec 3. On or about day of 20 whilst at the said premises 1 [P.T.O.

2 (ii) failing to have any or any adequate system of inspection and/or cleaning and/or repair of the said premises; (iii) failing to place any sign, notice, bollard, cordon or tape warning lawful visitors to the said premises of the need to exercise caution; (iv) For avoidance of doubt the Claimant will rely on the provisions of section 2(3) of the said Act whereby an occupier must be prepared for children to be less careful than adults. 5. By reason of the matters aforesaid the Claimant who was born on the day of sustained injuries and suffered distress, discomfort, inconvenience, loss and damage. 6. pec Particulars of Injuries The medical report of dated is annexed hereto. 2 Note 9. Note 10. Note 11. Note 12.

3 Note 13. Note 14. Particulars of Special Damages (Past and Future Expenses and Losses) And the Claimant seeks STATEMENT OF TRUTH [I believe][the Claimant believes] that the facts stated in these particulars of claim are true. Signed (i) (i) damages (ii) interest pursuant to section 69 of the County Courts Act Claimant. (ii) Litigation friend of Claimant. (iii) Legal representative of Claimant. pec Dated this day of 20 3 [P.T.O.

4 Client Ref No. This page is to be used whenever paragraph(s) within the main form need to be expanded upon. Please indicate by their respective number, which paragraph(s) are being added to Form No and Title: 7 Spa Road, London SE16 3QQ CONTINUATION SHEET pec Personal Injury - Form 4 (Occupiers Liability)

5 These notes are copyright and may not be reproduced. Notes for guidance for completion of the Particulars of Claim OCCUPIERS LIABILITY General - It is important that these notes are read thoroughly and that the guidance given to assist in completion of the Particulars of Claim is followed carefully. Note 1 - These particulars of Claim are intended for use in relatively straightforward cases where personal injury has been sustained as a result of the breach of the common duty of care under Section 2 of the Occupiers Liability Act They are not intended for use where the Claimant was a trespasser, as opposed to a lawful visitor. In the cases where the Claimant is a trespasser, different considerations apply and the law is governed by the Occupiers Liability Act Note 2 - Insert the name of the Court in which it is proposed to issue the claim. Note 3 - The Claim Number should be left blank since this will be provided by the Court in which the claim is issued. Note 4 - Insert the name of the Claimant. If the Claimant is a child, then after the child's name it should be stated that the Claimant is a child proceeding by his/her litigation friend and the name of the litigation friend should also be inserted. For example: JOHN SMITH (a child, proceeding by his Litigation Friend, John Brown) Claimant. Note 5 - Insert the name of the Defendant. This will be the person or company which occupies the premises in or on which the claimant sustained his injury. A person will be regarded as the occupier of the premises, if, for all intents and purposes, he has control over them. Note 6 - In this paragraph set out the name and address of the premises where the Claimant sustained the injury of which complaint is made. pec Note 7 - Insert the date on which the accident occurred and then, in the remaining space which has been provided, set out the facts of the Claimant's accident, i.e. how the Claimant's injuries were sustained. Use the continuation sheet if insufficient space is available here. Note 8 - In this paragraph have been set out particulars of negligence and/or breach of statutory duty under the 1957 Act which one would commonly expect to see in a pleading of this sort. Whilst they may not be of universal relevance, they should be relevant to most cases, e.g. where there has been a fall on spilt liquid or over some other object or defect which should not have been present. Any particulars which are not applicable to the facts of a case can simply be crossed through. Note 9 - Space has been left here for any particular allegation of negligence or breach of statutory duty which it is felt should be included and which is not covered by the standard particulars already set out on the form. Note 10 - Where the Claimant is a child, the pleading should contain the matters set out on the form at this point. If, however, the Claimant is an adult, then this should be crossed through. Note 11 - Insert the date of birth of the Claimant and give very brief particulars of any injuries sustained. Further down, give details of the medical report (i.e. the doctor preparing the report and the date on which it was prepared). Note 12 - This paragraph is appropriate only if there is to be a claim for provisional damages pursuant to Section 51 of the County Court Act In the vast majority of cases this will not be applicable and N/A can be inserted. Note 13 - Details of special damages should be inserted, i.e. all past and, if applicable, future losses. Examples include lost earnings; medical expenses (for example physiotherapy fees); prescription charges; cost of gratuitous care; taxis fares; telephone calls, etc. Note - Handicap on the labour market and loss of congenial employment, for example, would be regarded as aspects of general damages and if appropriate could be included on the continuation sheet available at the end of the form.

6 Note 14 - The Statement of Truth must be signed in every case either by the Claimant or, in the case of a child, by the Litigation Friend, or by the legal representative of the Claimant. N.B. - Please note, if there is insufficient room in any particular paragraph of the Particulars of Claim to write what is required, then simply put the words "see continuation sheet" and then complete what is required on the continuation sheet which is provided at the end of the Particulars of Claim. On the continuation sheet would first be written, for example, "particulars of special damages continued" or "paragraph 3 continued" as the case may be. pec Guidance on How to Issue the Claim in a County Court A Claim can be issued (started) in any County Court in England and Wales. Addresses and phone numbers can be found in the telephone book under the heading of Courts. Starting a Claim is very simple and Form N1 (the Claim Form) is available from Oyez and from any County Court Office and it is straightforward to complete. The Particulars of Claim will then be attached to the Claim form. Although Form N1 is easy to complete, the County Court Office will always give help if required. The Court will require a fee to issue the Claim and the fee will depend upon the amount being claimed. In some circumstances there may be no fee to pay. Details of fees are again available at the County Court Office. After the Claim is issued, the Court will then send a copy of it to the Defendant together with a Response Pack. The Response Pack contains the forms which the Defendant can use to reply to the Claim. The Response Pack contains an Admission form, a Defence form, and an Acknowledgement of Service. The Court sends these forms with the claim form and Particulars of Claim to the Defendant by first class post Spa Road, London SE16 3QQ Personal Injury - Form 4 (Notes) (Occupiers Liability)