52
STATEMENT OF CLAIM: fatal accident to driver of motor
vehicle1
[2553]
(Title as in Form 1)
Between
AB [[Executrix or Executor] of
the will or [Administratrix or
Administrator] of the Estate]
of JB, deceased ___ Plaintiff
and
CD [Sdn] Bhd and RS ___ Defendants
STATEMENT OF CLAIM
1. The Plaintiff is the [widow and/or executrix of the will or
administratix of the estate or widower and executor of the will or
administrator of the estate] of JB, deceased, who is hereinafter
referred to as ‘the deceased’, and brings this action in respect of
[her or his] bereavement2 and for the benefit of the dependants
of the deceased under the provisions of the Civil Law Act 1956
section 7 and for the benefit of the estate of the deceased under
the provisions of the Civil Law Act 1956 section 8. [Probate was
granted by or Letters of Administration were taken out of] the
(state relevant branch of High Court) Probate Registry on the
_________ day of _________ 20___.
2. On the _________ day of _________ 20___3 the
deceased was driving [his or her] (provide description) motor car
registration number ___ along the (provide description) main
road from ___ to ___ in the district of (name) when [s]he was
involved in a collision with a (provide description) lorry,
registration number ___, owned by the First Defendant and was
being driven by their servant or agent, the Second Defendant, on
to the said major road from a minor road, namely (state details).
3. The said collision was caused by the negligence of the
Second Defendant as servant and agent of the First Defendant.
PARTICULARS OF NEGLIGENCE
(Set out particulars as shown in Form 51)
4. By reason of the said negligence of the Defendants, the
deceased [was killed or died subsequently on the _________ day
of _________ 20___] by reason of the severe personal injuries
that [s]he had sustained, which had occasioned [him or her]
much pain and suffering whereby [his or her] dependants and
estate have suffered loss and damage.
PARTICULARS OF PERSONAL INJURIES
(Set them out only where there is a claim for pain and suffering of
the deceased between the happening of the accident
and the death)
PARTICULARS PURSUANT TO THE
CIVIL LAW ACT 1956 SECTION 7
(a) The persons, for whose benefit this action is brought, are
all the deceased’s dependants, namely:
(i) The Plaintiff, who is now aged [32] years;
(ii) Mrs OAP, the maternal grandmother4 of the
children referred to below, is a disabled widow,
aged [65] years, who has resided in the
matrimonial home for a number of years prior to
the death of the deceased;
(iii) MB, a child5 of the Plaintiff and the deceased’s born
on the _________ day of _________ 20___ now
aged [9] years.
(b) The nature of the claim is that the deceased who was aged
[33] years at the time of the death
[Either, in the case of a deceased husband:
was a strong healthy man who had worked continuously for the
[National Coal Board as a power loader at the (name and details)
colliery or as the case may be] since the age of 16 years. He
regularly worked overtime and his ‘take-home’ pay averaged
around RM______ per week, a substantial part of which was
spent for the benefit of the dependants and this would have
continued had he remained alive.
Or, in the case of a deceased wife:
used to look after the Plaintiff, her disabled mother and the
children. She was a strong healthy woman who was not only an
efficient housewife managing the home without assistance but
also worked [8] hours during the weekends as a part-time
housekeeper earning RM______ per week nett. Since and by
reason of her death, the Plaintiff has had to employ a
housekeeper from Monday to Friday each week at a weekly rate of
RM______ .]
Then:
(c) The funeral expenses were RM______.6
PARTICULARS OF SPECIAL DAMAGES
(i) Damage to the deceased’s motorcar RM______
(ii) Damage to the deceased’s clothing, jewellery
and personal belongings namely (specify) RM______
(iii Housekeeper’s wages at RM______ per week
) from RM______ and continuing RM______
RM______
5. AND the Plaintiff claims:
(a) General damages;
(b) Special damages in the sum of RM______;
(c) Interest7 thereon; and
(d) Costs of this action.
(Signature)
Plaintiff’s Solicitors
1 Under the Civil Law Act 1956 (Act 67) s 7, the plaintiff may bring the
action in his or her capacity as a dependant of the deceased, and
damages recovered by him or her do not form part of the estate of the
deceased. Under s 8 of the Act, the plaintiff will bring the action in his or her
name as personal representative of the deceased’s estate to recover
damages in respect of loss and damage to the deceased’s estate, including
any pain and suffering prior to his death. Exemplary damages, damages
for loss of income in respect of any period after the death of the deceased
and damages for bereavement cannot be claimed under s 8(2)(a) of the
Act. Where the death of the deceased has been caused by the act or
omission which gives rise to a cause of action, the damages
recoverable will be calculated without reference to any loss or gain to his
estate consequent on his death: s 8(2)(c). Loss of future earnings or
‘loss years’ is not a consequence of death and is therefore recoverable: Yap
Ami v Tan Hui Pang [1982] 2 MLJ 316, FC. See generally Charlesworth and
Percy on Negligence (8th Edn, 1993) ch 15. See also the current
edition (12th Edn, 2010).
2 This head of damage is only available where the death of the
deceased occurred after 1 October 1984. See the Civil Law
(Amendment) Act 1984 (Act A602) s 2(a) and XXIV [2222].
3 Where the death has occurred in a fatal accident claim either on or
before 1 October 1984, then the original provisions of the Civil Law
Act 1956 will still apply.
4 Ie who is a dependant of the deceased under the Civil Law Act 1956
s 7(2).
5 See note 4 above.
6 Damages may be awarded in respect of such expenses by virtue of
the Civil Law Act 1956 s 8(2)(c).
7 For interest on damages, see XXIV [2441].
