In the Court of Common Pleas of Philadelphia County
First Judicial District of Pennsylvania
Wrongful Death and Survival Actions Checklist
Pursuant to Pa.R.C.P. No 2206 and Phila. Civ. R. *2206
Assigned Trial Division/O.C. Judge:______________________________ Civil Case/O.C. # ________________________________________________________
Caption: ___________________________________________________________________________________________________________________________
Is this case disposed except for this petition? Yes No
If Yes, how was it disposed? S.D. & E. Jury Trial Non-Jury Trial
Other (explain)___________________________________________________________________________________________________________________
Consolidated Cases (List All Cases IDs): ______________________________________________________________________________________________
Have any Pleadings been filed in Orphans’ Court: Yes No
Are the following items included in the Petition: Yes No
1. Verification from Petitioner
2. Decedent’s date of death
3. Name of personal representative and the County of appointment
4. Identity of Decedent’s intestate heirs by name, date of birth, relationship and address
5. Identity of beneficiaries under Decedent’s Will by name, date of birth and address
6. Counsel’s reasons for approval of proposed settlement
7. Reasons for allocation between wrongful death and survival action
8. Reason and amount of pecuniary loss suffered by each beneficiary of Wrongful Death claim
9. Itemization of costs for which reimbursement is sought
Are the following items attached to the Petition:
1.
2.
3.
4.
5.
Decree of the Register of Wills granting Letters, and copy of the Will, if any
Order appointing Guardian, if guardian appointed for minor or incapacitated person
Copy of the notice sent to all parties in interest and Proof of Service upon those parties in
interest upon whom service was not effectuated through the Electronic Filing System
Statement of final lien/claim amount from Department of Human Services, Medicare and any other
entity claim or lien (Screen Shots will not be accepted)
Notice to and response of the Pennsylvania Department of Revenue
Does the Order of Distribution set forth the following:
1. Allocation of percentage of settlement amount between Wrongful Death and Survival claims
2. Counsel fee computed on net settlement amount for portion attributable to minor or incapacitated person
3. Counsel Costs
4. Final lien amount from Department of Human Services
5. Final demand or conditional payment amount from Medicare, if final demand not available
6. Name of settling defendants
7. Wrongful Death Claim
a. Amounts to spouse and adult children
b. Amounts to minor/incapacitated person (to be placed in restricted account not to exceed FDIC insured limit,
held in court approved trust, or paid to court appointed guardian)
c. Amounts to parent
8. Survival Claim: Payable to Administrator/Executor/rix of the Estate of the Deceased
9. Affidavit of Compliance to be filed certifying compliance with the Order
I verify the answers above to be true and correct and understand that sanctions may be imposed for inaccurate or incomplete answers
Date: ________________________ ________________________________________
11-10 (Rev. 11-9-23)
Notice of the filing of the Petition to the Department of Human Services (the affidavit of service must include the date of service).
*
* - A copy of the petition can be forwarded to [email protected]
