Injuries caused by negligence on a Railroad

Mr………………………….., the above-named plaintiff, states as follows :

1.	On the …………….. day of ………. 20…….., the defendants were common carries of passengers by railway between …….. and …….

2.	On that day the plaintiff was a passenger in one of the carriages of the  defendants on the said railway.

3.	While he was such passenger, at ……………….. [or near the  station of ………… or …… between the stations of …………….. and……….], a collision occurred on the said railway caused by the negligence and unskilfulness of the defendants servants, etc. and state the special damage, if any, as], and incurred expense for medical attendance and is permanently disabled from carrying on his former business as [a salesman]