Fill and Sign the Answers Interrogatories Form

_________________ : _______ JUDICIAL DISTRICT COURT VERSUS : PARISH OF _______ , LOUISIANA _________________ : DOCKET NO. ____ ______________________________________________________________________________ ANSWERS TO INTERROGATORIES NOW INTO COURT, through undersigned counsel, comes _________________ Plaintiff, who answers Defendant's, _________________ , interrogatories with respect shows: 1. Name: _________________ DOB: _______ ____ , ____ POB: _________________ , Louisiana Marital St: _______ Address: _________________ , _________________ SSN: _______ 2. I completed _________________ . 3. I have never been convicted of any crimes whatsoever. 4. I was traveling on _______ and my view was blocked by a cement truck traveling in my direction on my lane. The date of the accident was in the morning of _______ ____ , 20 ____ in _______ , Louisiana. 5. I have suffered severe neck pain as a result of the accident. 6. I have not fully recovered from the injuries sustained. 7. I still suffer a substantial amount of pain in my neck. 8. I was admitted to _________________ on _______ ____ , 20 ____ for injuries sustained from the accident. I am presently attending visits at _________________ , at _________________ , ____ ____ , LA ____ . 9. (11144) _________________ _________________ _________________ , LA ____ Intermediate Care on _______ ____ , 20 ____ and _______ ____ , 20 ____ $ ____ (2) _________________ _________________ ____ ____ , LA ____ Radiology Services on _______ ____ , 20 ____ and _______ ____ , 20 ____ . $ ____ _________________ _________________ ____ ____ , LA ____ Therapy, _______ ____ , 20 ____ through present. $ ____ 10. See Number 9 above. 11. I am presently undergoing treatment at _________________ , _________________ , ____ , LA ____ for the injuries sustained in this accident. 12. From _______ ____ , 20 ____ through _______ ____ , 20 ____ , I was employed by _________________ at $ ____ per hour and performing clerical work. From ____ to present, I am employed with _________________ as a cashier at $ ____ per hour. 13. On _______ ____ , 20 ____ , I was involved in an automobile accident at which time I sustained jaw, shoulder and back pain. I received medical treatment from _________________ , _________________ , _________________ and _________________ . A suit was never filed in connection to this accident. 14. (1) Not known at this time. (2) Not known at this time. (3) Not known at this time. 15. I am not claiming lost earning or loss of earnings capacity. 16. See attached. 17. No statements were taken from any individuals as to the nature of this accident. 18. At this time, we are unsure of who will be called as a witness for the defense. 19. See Number 18 above. 20. See attached. 21. I was driving at approximately 45 miles per hour at the time I became aware that an accident might result. 22. Suddenly appeared in my lane of travel, giving me no time to try to avoid an accident. 23. Unknown. 24. I was driving at approximately 45 miles per hour at the moment of impact. Respectfully Submitted, ____________________________ _________________ Attorney for Plaintiff _________________ _______ , LA ____ ( ____ ) _______