[IN THE COUNTY COURT AT [INSERT] OR IN THE HIGH COURT OF JUSTICE] [ [Specify division] ] [ [Insert location] DISTRICT REGISTRY ] Claim No: Between AB Claimant (the Widow and Executrix of the estate of A, deceased) and C Limited Defendant NOTE: On 2 December 2024, the Lord Chancellor announced that the discount rate would change to positive 0.5%. The positive 0.5% discount rate is effective from 11 January 2025. Schedule A1 to the Damages Act 1996 provides that each subsequent review must be started within the five-year period following the last review. For these purposes, a review is concluded when the Lord Chancellor makes the determination as to the rate. The Claimant reserves the right to alter, amend or add to this schedule at any time up to and including trial. Background data Deceased’s date of birth [date] Claimant’s date of birth [date] Claimant and deceased marry [date] First child [name] born [date] Second child [name] born [date] Accident [date] Date of deceased’s death [date] Proceedings issued [date] Assumed date of assessment [date] SCHEDULE OF LOSS DEPENDENCY CALCULATED TO [INSERT] Claim under the Law Reform (Miscellaneous Provisions) Act 1934 (LR(MP)A 1934) General Damages 1 As a result of the accident the deceased suffered [insert injuries]