Appendix XII-B1
CIVIL CASE INFORMATION STATEMENT FOR USE BY CLERK’S OFFICE ONLY
(CIS) PAYMENT TYPE: CK CG CA
CHG/CK NO.
AMOUNT:
OVERPAYMENT:
Use for initial Law Division
Civil Part pleadings (not motions) under Rule 4:5-1
Pleading will be rejected for filing, under Rule 1:5-6(c),
if information above the black bar is not completed or
if attorney’s signature is not affixed.
BATCH NUMBER:
ATTORNEY/PRO SE NAME
TELEPHONE NUMBER
COUNTY OF VENUE
FIRM NAME (If applicable)
DOCKET NUMBER (When available)
DOCUMENT TYPE OFFICE ADDRESS
JURY DEMAND
YES NO
NAME OF PARTY (e.g., John Doe, Plaintiff)
CAPTION
CASE TYPE NUMBER
(See reverse side for listing) IS THIS A PROFESSIONAL MALPRACTICE CASE? YES NO
IF YOU HAVE CHECKED “YES,” SEE N.J.S.A. 2A:53A-27 AND APPLICABLE CASE LAW REGARDING
YOUR OBLIGATION TO FILE AN AFFIDAVIT OF MERIT.
RELATED CASES PENDING?
YES NO
IF YES, LIST DOCKET NUMBERS
DO YOU ANTICIPATE ADDING
ANY PARTIES (arising out of same
transaction or occurrence)?
YES NO
NAME OF DEFENDANT’S PRIMARY INSURANCE COMPANY, IF KNOWN
ONE N
UNKNOWN
THE INFORMATION PROVIDED ON THIS FORM CANNOT BE INTRODUCED INTO EVIDENCE.
CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATION
DO PARTIES HAVE A CURRENT,
PAST OR RECURRENT
RELATIONSHIP? YES NO
IF YES, IS THAT
RELATIONSHIP EMPLOYER-EMPLOYEE FRIEND/NEIGHBOR THER (explain) O
FAMILIAL BUSINESS
DOES THE STATUTE GOVERNING THIS
CASE PROVIDE FOR PAYMENT OF FEES
BY THE LOSING PARTY?
YES NO
USE THIS SPACE TO ALERT THE COURT TO ANY SPECIAL CASE CHARACTERISTICS THAT MAY WARRANT INDIVIDUAL MANAGEMENT OR ACCELERATED
DISPOSITION:
DO YOU OR YOUR CLIENT NEED ANY
DISABILITY ACCOMMODATIONS? YES NO IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION:
WILL AN INTERPRETER BE NEEDED?
YES NO IF YES, FOR WHAT LANGUAGE:
I certify that confidential personal identifiers have been redacted from documents now submitted to the court, and will be
redacted from all documents submitted in the future in accordance with Rule 1:38-7(b).
ATTORNEY SIGNATURE:
Revised Effective 9/2009, CN 10517
CIVIL CASE INFORMATION STATEMENT
(CIS)
Use for initial pleadings (not motions) under Rule 4:5-1
CASE TYPES (Choose one and enter number of case type in appropriate space on the reverse side.)
Track I — 150 days' discovery
151 NAME CHANGE
175 FORFEITURE
302 TENANCY
399 REAL PROPERTY (other than Tenancy, Contract, Condemnation, Complex Commercial or Construction)
502 BOOK ACCOUNT (debt collection matters only)
505 OTHER INSURANCE CLAIM (INCLUDING DECLARATORY JUDGMENT ACTIONS)
506 PIP COVERAGE
510 UM or UIM CLAIM
511 ACTION ON NEGOTIABLE INSTRUMENT
512 LEMON LAW
801 SUMMARY ACTION
802 OPEN PUBLIC RECORDS ACT (SUMMARY ACTION)
999 OTHER (Briefly describe nature of action)
Track II — 300 days' discovery
305 CONSTRUCTION
509 EMPLOYMENT (other than CEPA or LAD)
599 CONTRACT/COMMERCIAL TRANSACTION
603 AUTO NEGLIGENCE – PERSONAL INJURY
605 PERSONAL INJURY
610 AUTO NEGLIGENCE – PROPERTY DAMAGE
699 TORT – OTHER
Track III — 450 days' discovery
005 CIVIL RIGHTS
301 CONDEMNATION
602 ASSAULT AND BATTERY
604 MEDICAL MALPRACTICE
606 PRODUCT LIABILITY
607 PROFESSIONAL MALPRACTICE
608 TOXIC TORT
609 DEFAMATION
616 WHISTLEBLOWER / CONSCIENTIOUS EMPLOYEE PROTECTION ACT (CEPA) CASES
617 INVERSE CONDEMNATION
618 LAW AGAINST DISCRIMINATION (LAD) CASES
620 FALSE CLAIMS ACT
Track IV — Active Case Management by Individual Judge / 450 days' discovery
156 ENVIRONMENTAL/ENVIRONMENTAL COVERAGE LITIGATION
303 MT. LAUREL
508 COMPLEX COMMERCIAL
513 COMPLEX CONSTRUCTION
514 INSURANCE FRAUD
701 ACTIONS IN LIEU OF PREROGATIVE WRITS
Centrally Managed Litigation (Track IV)
280 Zelnorm
285 Stryker Trident Hip Implants
Mass Tort (Track IV)
248 CIBA GEIGY 279 GADOLINIUM
266 HORMONE REPLACEMENT THERAPY (HRT) 281 BRISTOL-MYERS SQUIBB ENVIRONMENTAL
271 ACCUTANE 282 FOSAMAX
272 BEXTRA/CELEBREX 283 DIGITEK
274 RISPERDAL/SEROQUEL/ZYPREXA 284 NUVARING
275 ORTHO EVRA 286 LEVAQUIN
277 MAHWAH TOXIC DUMP SITE 601 ASBESTOS
278 ZOMETA/AREDIA 619 VIOXX
If you believe this case requires a track other than that provided above, please indicate the reason on Side 1,
in the space under "Case Characteristics."
Please check off each applicable category:
Verbal Threshold Putative Class Action Title 59
Revised Effective 9/2009, CN 10517
SIDE 2
