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DISC-004ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional ): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SHORT TITLE: FORM INTERROGATORIES– LIMITED CIVIL CASES (Economic Litigation) CASE NUMBER:Asking Party: Answering Party: Set No.: Sec. 1. Instructions to All Parties (b) As a general rule, within 30 days after you are served with(a) Interrogatories are written questions prepared by a party to these interrogatories, you must serve your responses on thean action that are sent to any other party in the action to be asking party and serve copies of your responses on all otheranswered under oath. The interrogatories below are form parties who have appeared. See Code of Civil Procedureinterrogatories approved for use in economic litigation. sections 2030.260–2030.270 for details.(b) For time limitations, requirements for service on other (c) Each answer must be as complete and straight-forward asparties, and other details, see Code of Civil Procedure the information reasonably available to you permits. If ansections 2030.010–2030.410 and the cases construing those interrogatory cannot be answered completely, answer it tosections. the extent possible. (c) These form interrogatories do not change existing law(d) If you do not have enough personal knowledge to fully relating to interrogatories, nor do they affect an answering answer an interrogatory, say so, but make a reasonable andparty's right to assert any privilege or make any objection. good faith effort to get the information by asking otherSec. 2. Instructions to the Asking Party persons or organizations, unless the information is equally(a) These interrogatories are designed for optional use byavailable to the asking party.parties under economic litigation in limited civil cases. See (e) Whenever an interrogatory may be answered by referring toCode of Civil Procedure sections 90 through 100. However, a document, the document may be attached as an exhibit tothese interrogatories also may be used in unlimited civil the response and referred to in the response. If thecases. document has more than one page, refer to the page and(b) There are restrictions on discovery for most limited civil section where the answer to the interrogatory can be found.cases. These restrictions limit the number of interrogatories (f)Whenever an address and telephone number for the samethat may be asked. For details, read Code of Civil person are requested in more than one interrogatory, youProcedure section 94. are required to furnish them in answering only the first(c) Some of these interrogatories are similar to questions in the interrogatory asking for that information.Case Questionnaire (form 982(a)(21)) and may be omitted if(g) Your answers to these interrogatories must be verified,the information sought has already been provided in adated, and signed. You may wish to use the following formcompleted Case Questionnaire. at the end of your answers:(d) Check the box next to each interrogatory that you want the I declare under penalty of perjury under the laws of theanswering party to answer. Use care in choosing those State of California that the foregoing answers are true andinterrogatories that apply to the case and are within thecorrect.restrictions discussed above. (e) You may insert your own definition of INCIDENT in Section 4, but only where the action arises from a course of conduct (DATE) (SIGNATURE)or a series of events occurring over a period of time.(f) The interrogatories in section 116.0, Defendant's Conten- Sec. 4. Definitionstions - Personal Injury, should not be used until defendanthas had a reasonable opportunity to conduct an Words in BOLDFACE CAPITALS in these interrogatories are defined as follows:investigation or discovery of plaintiff's injuries and damages. (Check one of the following):(g) Additional interrogatories may be attached, subject to the restrictions discussed above. (a) (1)INCIDENT includes the circumstances and events surrounding the alleged accident, injury, or other occurrence or breach of contract giving rise Sec. 3. Instructions to the Answering Party to this action or proceeding.(a) Subject to the restrictions discussed above, you mustanswer or provide another appropriate response to each interrogatory that has been checked below. Page 1 of 4Form Approved for Optional Use Code of Civil Procedure, §§ 94,Judicial Council of California 2030.010-2030.410, 2033.710DISC-004 [Rev. January 1, 2007] FORM INTERROGATORIES – LIMITED CIVIL CASE (Economic Litigation) electronic form  2005 WWW.LawCA.com Law Publishers DISC-004 (2) INCIDENT means (insert your definition here or on a 102.0 General Background Information - Individual separate, attached sheet labeled "Sec. 4(a) (2)"): 102.1 State your name, any other names by which you have been known, and your ADDRESS. 102.2 State the date and place of your birth.102.3 State, as of the time of the INCIDENT, your driver's (b) YOU OR ANYONE ACTING ON YOUR BEHALF license number, the state of issuance, the expiration date,includes you, your agents, your employees, your insurance and any restrictions.companies, their agents, their employees, your attorneys, youraccountants, your investigators, and anyone else acting on your 102.4 State each residence ADDRESS for the last fivebehalf. years and the dates you lived at each ADDRESS. (c) PERSON includes a natural person, firm, association,102.5 State the name, ADDRESS, and telephone numberorganization, partnership, business, trust, corporation, or public of each employer you have had over the past five years andentity. the dates you worked for each. (d) DOCUMENT means a writing, as defined in EvidenceCode section 250, and includes the original or a copy of hand- 102.6 Describe your work for each employer you have hadwriting, typewriting, printing, photostating, photographing,over the past five years.electronically stored information, and every other means of recording upon any tangible thing and form ofcommunicating or representation, including letters, words,102.7 State the name and ADDRESS of each academic orpictures, sounds, or symbols, or combinations of them. vocational school you have attended, beginning with high school, and the dates you attended each.(e) HEALTH CARE PROVIDER includes any PERSONreferred to in Code of Civil Procedure section 667.7(e)(3). 102.8 If you have ever been convicted of a felony, state, for each, the offense, the date and place of conviction, and the court and case number. (f) ADDRESS means the street address, including the city,state, and zip code.Sec. 5. Interrogatories 102.9 State the name, ADDRESS, and telephone numberThe following interrogatories have been approved by the of any PERSON for whom you were acting as an agent orJudicial Council under Code of Civil Procedure section 2033.710: employee at the time of the INCIDENT.CONTENTS 102.10 Describe any physical, emotional, or mental 101.0 Identity of Persons Answering These Interrogatories disability or condition that you had that may have102.0 General Background Information - Individual contributed to the occurrence of the INCIDENT.103.0 General Background Information - Business Entity104.0 Insurance 102.11 Describe the nature and quantity of any alcoholic105.0 [Reserved] beverage, marijuana, or other drug or medication of any106.0 Physical, Mental, or Emotional Injuries kind that you used within 24 hours before the INCIDENT.107.0 Property Damage108.0 Loss of Income or Earning Capacity 103.0 General Background Information - Business Entity109.0 Other Damages110.0 Medical History 103.1 State your current business name and ADDRESS,111.0 Other Claims and Previous Claims type of business entity, and your title.112.0 Investigation - General113.0 [Reserved] 104.0 Insurance114.0 Statutory or Regulatory Violations 104.1 State the name and ADDRESS of each insurance115.0 Claims and Defenses company and the policy number and policy limits of each116.0 Defendant's Contentions - Personal Injury policy that may cover you, in whole or in part, for the117.0 [Reserved] damages related to the INCIDENT.120.0 How the Incident Occurred - Motor Vehicle125.0 [Reserved] 105.0 [Reserved]130.0 [Reserved] 106.0 Physical, Mental, or Emotional Injuries135.0 [Reserved] 106.1 Describe each injury or illness related to the150.0 Contract INCIDENT.160.0 [Reserved]170.0 [Reserved] 106.2 Describe your present complaints about each 101.0 Identity of Persons Answering These injury or illness related to the INCIDENT.Interrogatories 101.1 State the name, ADDRESS, telephone number, and 106.3 State the name, ADDRESS, and telephone number relationship to you of each PERSON who prepared or of each HEALTH CARE PROVIDER who treated orassisted in the preparation of the responses to these examined you for each injury or illness related to theinterrogatories. (Do not identify anyone who simply typed or INCIDENT and the dates of treatment or examination.reproduced the responses.) Page 2 of 4DISC-004 [Rev. January 1, 2007] FORM INTERROGATORIES– LIMITED CIVIL CASE(Economic Litigation) DISC-004 106.4 State the type of treatment or examination given to 111.0 Other Claims and Previous Claims you by each HEALTH CARE PROVIDER for each injury or 111.1 Identify each personal injury claim that YOU ORillness related to the INCIDENT. ANYONE ACTING ON YOUR BEHALF have made within the past ten years and the dates. 106.5 State the charges made by each HEALTH CARE PROVIDER for each injury or illness related to the 111.2 State the case name, court, and case number ofINCIDENT. each personal injury action or claim filed by YOU OR 106.6 State the nature and cost of each health care service ANYONE ACTING ON YOUR BEHALF within the past ten related to the INCIDENT not previously listed (for example, years.medication, ambulance, nursing, prosthetics).112.0 Investigation - General 106.7 State the nature and cost of the health care services 112.1 State the name, ADDRESS, and telephone number you anticipate in the future as a result of the INCIDENT. of each individual who has knowledge of facts relating to theINCIDENT, and specify his or her area of knowledge. 106.8 State the name and ADDRESS of each HEALTH CARE PROVIDER who has advised you that you may need 112.2 State the name, ADDRESS, and telephone numberfuture health care services as a result of the INCIDENT. of each individual who gave a written or recorded statement relating to the INCIDENT and the date of the statement.107.0 Property Damage 112.3 State the name, ADDRESS, and telephone number107.1 Itemize your property damage and, for each item, of each PERSON who has the original or a copy of a written state the amount or attach an itemized bill or estimate. or recorded statement relating to the INCIDENT.108.0 Loss of Income or Earning Capacity 112.4 Identify each document or photograph that describes or depicts any place, object, or individual concerning the INCIDENT or plaintiff's injuries, or attach 108.1 State the name and ADDRESS of each employer or a copy. (if you do not attach a copy, state the name, other source of the earnings or income you have lost as a ADDRESS, and telephone number of each PERSON result of the INCIDENT. who had the original document or photograph or a copy.) 108.2 Show how you compute the earnings or income you 112.5 Identify each other item of physical evidence that have lost, from each employer or other source, as a result of shows how the INCIDENT occurred or the nature or extentthe INCIDENT. of plaintiff's injuries, and state the location of each item, and the name, ADDRESS, and telephone number of each PERSON who has it. 108.3 State the name and ADDRESS of each employer or other source of the earnings or income you expect to lose inthe future as a result of the INCIDENT. 113.0 [Reserved] 108.4 Show how you compute the earnings or income you 114.0 Statutory or Regulatory Violations expect to lose in the future, from each employer or othersource, as the result of the INCIDENT. 114.1 If you contend that any PERSON involved in theINCIDENT violated any statute, ordinance, or regulation and109.0 Other Damages that the violation was a cause of the INCIDENT, identify 109.1 Describe each other item of damage or cost that you each PERSON and the statute, ordinance, or regulation. attribute to the INCIDENT, stating the dates of occurrenceand the amount. 115.0 Claims and Defenses110.0 Medical History 115.1 State in detail the facts upon which you base your110.1 Describe and give the date of each complaint or claims that the PERSON asking this interrogatory is injury, whether occurring before or after INCIDENT, thatresponsible for your damages.involved the same part of your body claimed to have beeninjured in the INCIDENT. 115.2 State in detail the facts upon which you base your contention that you are not responsible, in whole or in part, 110.2 State the name, ADDRESS, and telephone number for plaintiff's damages. of each HEALTH CARE PROVIDER who examined ortreated you for each injury or complaint, whether occurring 115.3 State the name, ADDRESS, and the telephonebefore or after the INCIDENT, that involved the same part of number of each PERSON, other than the PERSON askingyour body claimed to have been injured in the INCIDENT this interrogatory, who is responsible, in whole or in part, forand the dates of examination or treatment. damages claimed in this action. Page 3 of 4DISC-004 [Rev. January 1, 2007] FORM INTERROGATORIES– LIMITED CIVIL CASE(Economic Litigation) DISC-004116.0 Defendant's Contentions - Personal Injury 120.4 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of each [See Instruction 2(f)] occupant other than the driver. 116.1 If you contend that any PERSON, other than you or plaintiff, contributed to the occurrence of the INCIDENT or 120.5 For each vehicle involved in the INCIDENT, state thethe injuries or damages claimed by plaintiff, state the name, name, ADDRESS, and telephone number of each regis-ADDRESS, and telephone number of each individual who tered owner.has knowledge of the facts upon which you base yourcontention. 120.6 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of each lessee. 116.2 If you contend that plaintiff was not injured in the INCIDENT, state the name, ADDRESS, and telephone 120.7 For each vehicle involved in the INCIDENT, state thenumber of each individual who has knowledge of the facts name, ADDRESS, and telephone number of each ownerupon which you base your contention. other than the registered owner or lien holder. 116.3 If you contend that the injuries or the extent of the 120.8 For each vehicle involved in the INCIDENT, state the injuries claimed by plaintiff were not caused by the name of each owner who gave permission or consent to theINCIDENT, state the name, ADDRESS, and telephone driver to operate the vehicle.number of each individual who has knowledge of the factsupon which you base your contention. 150.0 Contract 116.4 If you contend that any of the services furnished by 150.1 Identify all DOCUMENTS that are part of the any HEALTH CARE PROVIDER were not related to the agreement and for each state the name, ADDRESS, andINCIDENT, state the name, ADDRESS, and telephone telephone number of the PERSON who has each DOCU-number of each individual who has knowledge of the facts MENT.upon which you base your contention. 150.2 State each part of the agreement not in writing, the116.5 If you contend that any of the costs of services name, ADDRESS, and telephone number of each PERSON furnished by any HEALTH CARE PROVIDER were agreeing to that provision, and the date that part of theunreasonable, identify each service that you dispute, the agreement was made.cost, and the HEALTH CARE PROVIDER. 150.3 Identify all DOCUMENTS that evidence each part of116.6 If you contend that any part of the loss of earnings or the agreement not in writing, and for each state the name, income claimed by plaintiff was unreasonable, identify each ADDRESS, and telephone number of the PERSON whopart of the loss that you dispute and each source of the has each DOCUMENT.income or earnings. 150.4 Identify all DOCUMENTS that are part of each mod- ification to the agreement, and for each state the name 116.7 If you contend that any of the property damage ADDRESS, and telephone number of the PERSON who claimed by plaintiff was not caused by the INCIDENT, has each DOCUMENT.identify each item of property damage that you dispute. 150.5 State each modification not in writing, the date, and the name, ADDRESS, and telephone number of the PERSON agreeing to the modification, and the 116.8 If you contend that any of the costs of repairing the date the modification was made. property damage claimed by plaintiff were unreasonable,identify each cost item that you dispute. 150.6 Identify allDOCUMENTSthat evidence each 116.9 If you contend that, within the last ten years, plaintiff modification of the agreement not in writing and for each made a claim for personal injuries that are related to the state the name, ADDRESS, and telephone number of theinjuries claimed in the INCIDENT, identify each related injury PERSON who has each DOCUMENT.and the date. 150.7 Describe and give the date of every act or omission116.10 If you contend that, within the past ten years, that you claim is a breach of the agreement. plaintiff made a claim for personal injuries that are related tothe injuries claimed in the INCIDENT, state the name, court, 150.8 Identify each agreement excused and state why per-and case number of each action filed. formance was excused.117.0 [Reserved] 150.9 Identify each agreement terminated by mutual agree-120.0 How the Incident Occurred - Motor Vehicle ment and state why it was terminated, including dates. 120.1 State how the INCIDENT occurred.150.10 Identify each unenforceable agreement and state120.2 For each vehicle involved in the INCIDENT, state the the facts upon which your answer is based. year, make, model, and license number. 120.3 For each vehicle involved in the INCIDENT, state the 150.11 Identify each ambiguous agreement and state the name, ADDRESS, and telephone number of the driver. facts upon which your answer is based. Page 4 of 4DISC-004 [Rev. January 1, 2007] FORM INTERROGATORIES–LIMITED CIVIL CASE(Economic Litigation)