M Civ JI 67.01 Form of Verdict: No-Fault First-Party Benefits Action

We, the jury, make the following answers to the questions submitted by the Court:

QUESTION NO. 1: Did the plaintiff sustain an accidental bodily injury?

A. Answer: ____(yes or no)

B. If your answer is “no,” do not answer any further questions.

QUESTION NO. 2: Did the plaintiff’s accidental bodily injury arise out of the ownership, operation, maintenance, or use of a motor vehicle as a motor vehicle [ on [ date ] / during the period of [ specify dates ]? ]

A. Answer: ____(yes or no)

B. If your answer is “no,” do not answer any further questions.

ALLOWABLE EXPENSES

QUESTION NO. 3: Were allowable expenses incurred by or on behalf of the plaintiff arising out of the accidental bodily injury referred to in QUESTION NO. 2?

(Allowable expenses consist of all reasonable charges for reasonably necessary products, services, and accommodations for the plaintiff’s care, recovery, or rehabilitation.)

Answer: ____ (yes or no)

If your answer is “yes,” what is the amount of allowable expenses owed to the plaintiff (include only expenses not already paid by the defendant)?

$____________

WORK LOSS

QUESTION NO. 4: Did the plaintiff sustain work loss arising out of the accidental bodily injury referred to in QUESTION NO. 2?

(Work loss consists of loss of income from work the plaintiff would have performed during the first three years after the date of the accident if the plaintiff had not been injured. *[ Work loss for an injured person who is temporarily unemployed at the time of the accident or during the period of disability shall be based on earned income for the last month employed full time preceding the accident. ] Work-loss benefits are computed at 85 percent of the plaintiff’s loss of gross income, but they may not exceed the sum of [ applicable monthly maximum ] per 30-day period nor may they be payable beyond three years after the date of the accidental bodily injury.)

A. Answer: ____ (yes or no)

B. If your answer is “yes,” what is the amount of work loss owed to the plaintiff (include only work loss not already paid by the defendant)?

$____________

REPLACEMENT SERVICE EXPENSES

QUESTION NO. 5: Were replacement service expenses incurred by or on behalf of the plaintiff arising out of the accidental bodily injury referred to in QUESTION NO. 2?

(Replacement service expenses consist of expenses not exceeding $20 per day reasonably incurred in obtaining ordinary and necessary services in place of those that, if the plaintiff had not been injured, the plaintiff would have performed during the first three years after the date of the accident, not for income, but for the benefit of the plaintiff or [ his / her ] dependent(s). Benefits for replacement service expenses may not exceed $20 per day nor may they be payable beyond three years after the date of the accidental bodily injury.)

A. Answer: ____ (yes or no)

B. If your answer is “yes,” what is the amount of replacement service expenses owed to the plaintiff (include only replacement service expenses not already paid by the defendant)?

$____________

SURVIVOR’S LOSS; FUNERAL AND BURIAL EXPENSES

QUESTION NO. 6: Did [ name of decedent ]’s death result from the accidental bodily injury referred to in QUESTION NO. 2?

Answer: ____(yes or no)

If your answer is “no,” do not answer QUESTION NO. 7 or QUESTION NO. 8. Answer QUESTION NO. 9.

If your answer is “yes,” answer QUESTION NO. 7.

QUESTION NO. 7: Did the dependents of [ name of decedent ] incur survivor’s loss?

(Survivor’s loss consists of two categories of loss: (1) a loss of tangible things of economic value that the dependents would have received for their support during their dependency if [ name of decedent ] had not died. This includes the after-tax income of [ name of decedent ] plus the value of [ his / her ] lost fringe benefits, and (2) replacement service expenses not exceeding $20 per day reasonably incurred by the dependents during their dependency and after the death of [ name of decedent ] in obtaining ordinary and necessary services in place of those that [ name of decedent ] would have performed for their benefit if [ he / she ] had not died. The benefits payable for both categories of survivor’s loss may not exceed the sum total of [ applicable monthly maximum ] per 30-day period nor may they be payable beyond three years after the date of the accidental bodily injury.)

A. Answer: ____ (yes or no)

B. If your answer is “yes,” what is the total amount of survivor’s loss owed to the plaintiff (include only the loss not already paid by the defendant)?

$____________

QUESTION NO. 8: Were funeral and burial expenses incurred as a result of the death of [ name of decedent ]?

(Funeral and burial expenses may not exceed the lesser of the amount incurred or [ insert policy maximum ].)

A. Answer: ____ (yes or no)

B. If your answer is “yes,” what is the amount of funeral and burial expenses owed to the plaintiff (include only those expenses not already paid by the defendant)?

$____________

INTEREST

QUESTION NO. 9: Was payment for any of the expenses or losses to which the plaintiff was entitled overdue?

(Payment for an expense or loss is overdue if it is not paid within 30 days after the defendant receives reasonable proof of the fact and the amount of the claim. An overdue claim bears interest at the rate of 12 percent per annum from the date the expense or loss became overdue.)

A. Answer: ____ (yes or no)

B. If your answer is “yes,” what is the amount of interest owed to the plaintiff on overdue benefits (include only interest not already paid by the defendant)?

$____________

Signed,

______________________________ _______________________

Foreperson Date

Note on Use

*The bracketed sentence in QUESTION NO. 4 should be used if the injured person is temporarily unemployed.

If the plaintiff is not the injured person, substitute the name of the injured person for the word “plaintiff” where necessary.

See MCL 500.3107(1)(a) for the statutory minimum and maximum for funeral and burial expenses.

Omit any questions that are not at issue, such as whether the injuries arose out of the ownership, operation, maintenance, or use of a motor vehicle, and any benefits that are not claimed by the plaintiff.

This Special Verdict Form may have to be modified where there are questions involving coordination of benefits, governmental setoffs, or other issues arising under the no-fault statutes that are not specifically addressed by the format set forth.

For applicable monthly maximum, see Note on Use to M Civ JI 35.01.

History

M Civ JI 67.01 was added February 1981. Amended May 1999.