Fill and Sign the Answers to Interrogatories Mississippi Form

BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION       CLAIMANT V. NO.             EMPLOYER AND       CARRIER ANSWERS TO INTERROGATORIES COMES NOW the Claimant,       , styled and numbered cause, and fles this, the Interrogatories propounded to him by the Carrier, and in answering says: 1. Please state your full legal name and any other aliases by which you have been known and the dates during which you were known by each such in the above his Answers to Employer and ANSWER:       , nicknames - "       ", "       " and "       ." 2. Please state each residence address you have had during the immediately preceding ten years, including your present residence address and the inclusive dates you have lived at each such address and include the names and present addresses of each and every person residing with you at each such resident address during said time period. ANSWER:       ,       , MS,       ;       ,       , MS,       ;       ,       , MS. Claimant lives with and/or special courses taken. ANSWER:       . 5. Please describe all vocational or occupational training programs in which you have been involved, and describe any special certifcations or degrees or certifcates received. ANSWER:       . 6. Please describe all hobbies and sporting activity in which you have engaged and the inclusive dates of participation in those activities. ANSWER:       . 7. Please describe your employment history, including military services, prior to your accident with the employer herein, such description to include as to each employment (and/or self - employment) relationship, the name and address of each such employer (and/or business), the name of your supervisor, the dates of each such employment, the type of work performed by you while so employed and the reason for termination of such prior employment. ANSWER:       . 8. Please describe fully the accident which is the subject matter of this claim, such description to include the precise date, time, and location of said accident, the activities in which you were engaged at the time of the accident and a full detailed description of how the accident occurred. ANSWER:       . 9. Please list the name, residence address, business address and telephone number of each person known or reasonably felt by you, your attorney, or other representative to be (a) an eyewitness to the alleged accident which is the subject matter of this claim; (b) a person having knowledge of some fact or circumstance relating to said alleged accident; (c) a person having knowledge of some fact or circumstance relating to your medical condition for which claim is made herein; and/or (d) a person having knowledge of some fact or circumstance relating to your temporary disability, permanent disability, alleged loss of wage earning capacity and/or functional loss of use which you allege to have resulted from the accident made the basis of this workers'       . 10. Please state the name, residence address, business address and telephone number of the person to whom you gave notice of your alleged accident, the date, time, and place wherein such notice was given, and state exactly what you told said person regarding your alleged accident and state said person's response. ANSWER:       . 11. Please describe the nature of the medical condition for which you are making claim herein, such description to include the part of your body involved and the extent of such condition. ANSWER:       . 12. Please list the name, specialty, business address and telephone number of each doctor, physician, surgeon, psychiatrist, psychologist or other medical practitioner who has examined, evaluated and/or treated you for your alleged injuries or medical condition for which claim is being made herein and list the frst and last dates of said examination, evaluation or treatment for each. ANSWER:       . ANSWER:       . 13.       14. State your height and weight on 20       , and your present height and weight. ANSWER:       . 15. List each and every medical, hospital and/or doctor bill which you have incurred and/or shall incur as a result of the injury alleged in your Petition to Controvert, stating the amount of such bill, the date of such bill, the name of the creditor and/or provider, the date such bill was presented to employer and/or carrier and the method of presentation, the amount paid on said bill and the date of payment and the payor, and/or the amount outstanding on said bill. ANSWER:       . 16. Please describe your employment history since the accident which is the subject matter of this claim, such description to include the name, business address, and telephone number of each employer for whom you have worked, the dates of each such employment, your pay rate, salary and/or wages, your job title, the name of your supervisor and a description of the work activities performed by you and, in addition, if you have been self employed, provide the name, address and telephone number of your business, the nature of your business, the dates and time periods of such self       . 17. Please describe your attempts to fnd employment since your accident stated in your petition to controvert, etc. ANSWER:       18. In the event you received medical treatment for the medical condition which is the subject of this claim before your accident described in your petition to controvert, please describe such medical treatment to include the date of such treatment, the nature of the injury or medical condition for which treatment was received, and the name, address and telephone number of each doctor or other medical practitioner who examined and/or treated you therefore. ANSWER:       . 19. Other than the accident which is the subject matter of claim, please describe any other accidents and/or injuries you have had involving any part of your body whatsoever, such description to include the dates of each such accident or injury, the part of your body involved and the name, address number and telephone number of each doctor or other medical practitioner who examined and/or treated you therefore. ANSWER:       . 20. If you have fled any suit or made any claim, formally or informally, for damages or any sum of money whatsoever against any parties other than the employer and/or carrier in this worker's compensation case, please state the name, residence address, business address and telephone number of the party or parties against whom such suit was fnger. 21. Please describe all medical treatment and/or medical examinations you have received during the ten years before the date of the accident described in your petition to controvert, such description to include the name, address and telephone number of each doctor or other medical practitioner seen by you. The nature of the medical condition for which such treatment, evaluation or examination was received. ANSWER:       . 22. Please describe all medical treatment and/or medical examinations you have received since the accident described in your petition to co9trovert for medical problems other than those for which claim is being made herein, such description to include the name, address and telephone number of each doctor or other medical practitioner seen by you, the date of each treatment, evaluation and/or examination, and the nature of the medical condition for which such treatment, evaluation or examination was received. ANSWER:       . 23. If you have ever pled guilty to or been convicted of a crime please state, with reference to each such conviction or guilty plea, the nature of the crime, the date of the conviction/guilty plea and the name and address of the court in which said crime was administered. ANSWER:       . 24. State each and every fact and circumstance upon which you contend that you have any permanent disability, loss of use and/or loss of wage earning capacity as a result       . ANSWER:       . 25. Please state the name, residence address, business address and telephone number of each and every person you intend to call as a witness in this cause, and give a summary of the testimony you expect to ofer from each witness named. ANSWER:       . 26. Please state the name, residence address, business address, telephone number and specialty of each and every expert witness, including medical and/or vocational experts, you expect to call as a witness in this cause, and state the subject matter on which the expert is expected to testify, state the substance of the facts and opinions to which each such expert is expected to testify and a summary of the grounds for each opinion and state each expert's qualifcations for rendering such opinion. ANSWER:       . ANSWER:       . 25. Please state the name, residence address, business address and telephone number of each and every person you intend to call as a witness in this cause, and give a summary of the testimony you expect to ofer from each witness named. ANSWER:       . 26. Please state the name, residence address, business address, telephone number and specialty of each and every expert witness, including medical and/or vocational experts, you expect to call as a witness in this cause, and state the subject matter on which the expert is expected to testify, state the substance of the facts and opinions to which each such expert is expected to testify and a summary of the grounds for each opinion and state each expert's qualifcations for rendering such opinion. ANSWER:       . ANSWER:       . Dated this the       day of       , 20       . Respectfully submitted,