FORM 21. Civil Appeal Statement (Rule 5.5(c)) COURT OF APPEALS, DIVISION ___ OF THE STATE OF WASHINGTON (Title of trial court proceeding ) with parties designated as in ) CIVIL APPEAL STATEMENT rule 3.4) ) 1. NATURE OF THE CASE AND DECISION (State the substance of the case below and the basis for the trial court decision. For example: "Defendant was driving his automobile when struck from the rear by a truck driven by Jones. An automobile coming from the opposite direction driven by an uninsured motorist crossed the center line into the lane occupied by defendant and collided with the defendant's car. Defendant settled his claim against Jones and executed a release without the consent of plaintiff insurance company. The policy issued by plaintiff contained a provision which excluded coverage under the uninsured motorist provisions for bodily injury to an insured who has made any settlement with any person without the written consent of the company. The trial court held that this exclusion violated public policy by restricting the uninsured motorist coverage required by RCW 48.22.030 and declared the exclusion void.") 2. ISSUES PRESENTED FOR REVIEW (State the issues the party intends to present for review by the Court of Appeals. For example: "Whether a provision which excludes coverage when the insured does not secure the insurer's consent before settling with any person responsible for any injury violates public policy by restricting the uninsured motorist coverage required by RCW 48.22.030?" List under each issue the legal authority relevant to that issue.) 3. RELIEF SOUGHT IN COURT OF APPEALS (State the relief the party seeks in the Court of Appeals. For example: "Reversal of trial court decision with directions to enter judgment declaring that defendant is not covered by the uninsured motorist provisions of the liability policy issued by plaintiff.") 4. TRIAL COURT (Name of County) County Superior Court 5. JUDGE (Name of Trial Court Judge) 6. DATE OF DECISION (The date the decision was entered in the trial court) 7. POST-DECISION MOTIONS (State each post-decision motion made in the trial court including the nature of the motion, the date the motion was made, the decision on the motion, and the date the decision was entered.) 8. NOTICE OF APPEAL The notice of appeal was filed on date. A copy of the notice of appeal is attached to this statement. 9. COUNSEL Counsel for appellant (name of appellant) is (name, address, and telephone number of attorney). Counsel for respondent (name of respondent) is (name, address, and telephone number of attorney). 10. METHOD OF DISPOSITION IN TRIAL COURT (State the method used to decide the case in the trial court. For example: "summary judgment, order of dismissal, judgment after trial to the court, judgment after jury trial.") 11. RELIEF GRANTED BY TRIAL COURT (State the relief granted by the trial court. For example: "The trial court entered a judgment declaring that defendant has coverage under the uninsured motorist provisions of the automobile liability policy issued by plaintiff.") 12. RELIEF DENIED BY TRIAL COURT (State the relief sought by the party making the statement which was denied by the trial court. For example: "Plaintiff sought a judgment declaring that the uninsured motorist provision of the automobile liability policy no longer provided coverage to defendant.") 13. CERTIFICATE OF COUNSEL I, attorney for appellant (name of appellant), certify that this appeal is taken in good faith and not for purposes of delay. I further certify that my client (is or is not) prepared to immediately take all steps to complete the appeal. (If the statement indicates the party is not prepared to immediately take all steps to complete the appeal, state here why the party is not prepared to immediately complete the appeal.) (Date) _____________________________________ Signature Attorney for Appellant (Name, address, telephone number, and Washington State Bar Association membership number of attorney)
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