[CAPTION]

Plaintiffs __________ and __________ allege against all defendants as follows:

1. The injury to plaintiff __________ complained of herein occurred at __________, in the City of
__________, County of __________, State of California on __________, 20__.
2. Plaintiff __________ is a resident of the County of __________, State of California.
3. Plaintiffs are informed and believe, and thereon allege, that at all times mentioned herein
defendants __________, Does 1-100, and each of them, are business entities, and at all times mentioned herein
were, form unknown, actually doing business in __________ County, California.
4. Plaintiffs are informed and believe, and thereon allege, that plaintiff's employer and defendant,
__________ and Does 1-100, and each of them, are, and at all times mentioned herein were, a corporation duly
organized and existing under the laws of the State of California with its principal place of business in the City of
__________, County of __________, State of California. Plaintiffs are informed and believe, and thereon allege,
that said employer is duly licensed to do business, and was doing business, under and by the virtue of the laws of the
State of California.
5. Plaintiffs are ignorant of the true names and capacities of defendants sued herein as Does 1-100,
inclusive, and therefore sue these defendants by such fictitious names. Plaintiffs pray leave to amend this Complaint
to assert the true names of said defendants when such information becomes available.
6. Plaintiffs are informed and believe, and thereon allege, that each fictitiously-named defendant is
negligently or otherwise responsible in some manner for the occurrences herein alleged, and that plaintiffs' injuries
and damages were legally caused by said negligence or other conduct.

____________ CAUSE OF ACTION

[Breach of Statutory Duty - Labor Code Section 4558]
1. Plaintiffs incorporate by reference paragraphs 1 through 35 as though fully set forth herein.
2. At all times mentioned herein, defendants __________ and Does 1-100, and each of them, were
the employer of plaintiff __________, and prior to plaintiff’s injury at the aforementioned power press machine on
or about __________, 20__ were owners or supervisors having managerial authority to direct and control the acts of
their employees.
3. Defendants __________ and Does 1-100, and each of them, obtained said power press machine
from the manufacturer who designed, installed, required or otherwise provided for a device designed to guard
operators against the possibility of being injured at the point of operation on the press.
4. The manufacturer of said power press machine conveyed knowledge to the employer, defendants
__________ and Does 1-100, and each of them, that the attachment or use of the safety guarding device had been
designed, installed, required or otherwise provided for by specification for the proper and safe use of said power
press machine.
5. Before, on or about __________, 20__, plaintiff’s employer, defendants __________ and Does 1-
100, and each of them, knowingly failed to install or knowingly removed the safety guarding device at the point of
operation on said power press machine. Such failure to install or knowing removal was specifically authorized by
plaintiff's employer, defendants __________ and Does 1-100, and each of them, who knew that this failure to install
or knowing removal gave rise to conditions creating a probability of serious injury or death to users or operators of
said power press machine.
6. While engaged in his activities and job duties as the operator of said power press machine, before,
on, or about __________, 20__, plaintiff operated said power press machine for the benefit and service of, and at the
direction and behest of, his employer, defendants __________ and Does 1-100, and each of them. On or about
__________, 20__, as a legal result of the aforementioned failure to install or knowing removal of the safety
guarding device on said power press machine, serious and severe injuries were caused to plaintiff __________ while
plaintiff used said power press machine for the purpose for which it was intended.
7. As a legal result of the above described failure to install or knowing removal of the safety
guarding device on said power press machine, plaintiff __________ was hurt and injured in his health, strength, and
activity, sustaining injury to his nervous system and person, all of which injuries have caused and will continue to
cause plaintiff great mental, physical, and nervous pain and suffering. Plaintiffs are informed and believe and there-
on allege that such injuries will result in some permanent disability to him. As a result of such injuries, plaintiffs
have suffered general damages in an amount to be proven at the time of the trial of this action.
8. As a further legal result of the above described failure to install or knowing removal of the safety
guarding device on said power press machine, plaintiff __________ has incurred, and will continue to incur, medical
and related expenses for physicians, surgeons, hospital care, and other medical services and supplies. The full
amount of these expenses is not known to plaintiffs at this time. Plaintiffs pray leave to amend this Complaint to
state the amount when it becomes known to him.
9. As a further legal result of the above described failure to install or knowing removal of the safety
guarding device on said power press machine, plaintiff __________ has necessarily suffered a loss of earnings, and
plaintiffs are informed and believe, and thereon allege, that he will continue such a loss for an indefinite time in the
future. Plaintiff's earning capacity has been greatly reduced, all to plaintiff’s further special damages in amounts
currently unknown. Plaintiffs pray leave to amend this Complaint to assert the true amounts when they are
ascertained.
10. Defendants __________ and Does 1-100, and each of them, in failing to install or in knowingly
removing the safety guarding device on said power press machine, engaged in conduct in conscious disregard of
plaintiff's rights and safety in that defendants __________ and Does 1-100, and each of them, knew, pursuant to the
requirements or instructions of the manufacturer of said power press or its agents, that a safety guarding device had
been designed, installed, required or otherwise provided for the operation of the power press by specification for the
proper and safe use of said power press machine. Said conduct of defendants __________ and Does 1-100, and each
of them, was done knowing of the dangers presented to plaintiff and other users of the machine by reason of the lack
of safety guarding device, namely the risk of serious injury, disfiguring burns, mayhem or death. In failing to install
or in knowingly removing point of operation guards on said power press machine, defendants __________ and Does
1-100, and each of them, acted with oppression, fraud, and malice because said conduct was despicable conduct
carried on with a willful and conscious disregard of plaintiff’s rights, said conduct was despicable conduct
subjecting plaintiff to cruel and unjust hardship in conscious disregard of plaintiff’s rights, and said conduct was
deceit which caused injury to plaintiff, thereby giving rise to punitive or exemplary damages.
WHEREFORE, plaintiffs pray judgment against defendants _____________, __________ and Does 1-100,
and each of them as hereinafter set forth.

WHEREFORE, plaintiffs pray for judgment against defendants __________ and Does 1-100, and each of
them on the theories of action Four and Five, as follows:
1. For general damages according to proof;
2. For special damages according to proof;
3. For exemplary damages according to proof;
4. For interest to the extent allowable by law;
5. For costs of the suit herein; and
6. For such further relief as the court may deem proper.

Form contributed by:

Kevin Lancaster
Law Offices of William L. Veen P.C.
San Francisco