Support Services for Our Community

SMALL CLAIMS COMPLAINT FORM

(For claims under $50,000 related to an autonomous vehicle incident)

Plaintiff (Injured Party):

• Full Name: [Your Name]

• Address: [Your Address]

• Phone Number: [Your Phone]

• Email: [Your Email]

Defendant (Autonomous Vehicle Manufacturer):

• Company Name: [Manufacturer Name]

• Registered Agent (if known): [Agent Name]

• Address of Headquarters: [Company Address]

Jurisdiction & Venue:

This complaint is filed in [County Name] Small Claims Court, as the damages sought do not exceed $50,000, and the incident occurred within this jurisdiction.

Statement of Claim:

• Nature of the Incident:
On [date of incident], I was involved in a collision or incident with an autonomous vehicle manufactured by [Manufacturer Name] at [Location]. The vehicle, operating in autonomous mode, (e.g., failed to stop, made an unsafe maneuver, misidentified an object, etc.), resulting in damages to my (vehicle, property, body, etc.).

• Damages:
As a result of the incident, I have suffered the following damages:

• Property Damage: $[amount] (e.g., repair costs, loss of use)

• Medical Expenses: $[amount] (e.g., hospital visits, therapy, rehabilitation)

• Lost Wages: $[amount] (if applicable)

• Other Expenses: $[amount] (e.g., transportation, insurance deductibles)

• Legal Basis for the Claim:

• The autonomous vehicle system failed to operate as a reasonably prudent driver would under the same circumstances.

• The vehicle manufacturer’s system did not adequately account for real-world driving conditions, contributing to the accident.

• Why This Claim Benefits the Manufacturer:

• This lawsuit is an opportunity for [Manufacturer Name] to identify and resolve real-world driving challenges, preventing future, larger lawsuits.

• A structured small-claims process reduces the risk of class-action litigation and negative regulatory intervention.

• By addressing small, legitimate consumer grievances early, the company can maintain public trust and improve its technology.

Relief Sought:

I seek a total judgment in the amount of $[Total Damages], which includes compensation for damages, out-of-pocket costs, and any incidental expenses related to this incident.

Request for Court Hearing:

I request a hearing at the earliest possible date to present my case.

Signature & Date:

Plaintiff’s Signature: _______________________
Date: ______________