Fill and Sign the B for Time Limitations Requirements for Service on Other Parties Form

DISC-002ATTORNEY 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 – EMPLOYMENT LAW CASE NUMBER:Asking Party: Answering Party: Set No.: Sec. 1. Instructions to All Parties (c) Each answer must be as complete and straightforward(a) Interrogatories are written questions prepared by a party to an as the information reasonably available to you permits. If action that are sent to any other party in the action to be an interrogatory cannot be answered completely,answered under oath. The interrogatories below are form answer it to the extent possible. interrogatories approved for use in employment cases. (d) If you do not have enough personal knowledge to fully(b) For time limitations, requirements for service on other parties, answer an interrogatory, say so, but make a reasonableand other details, see Code of Civil Procedure sections and good faith effort to get the information by asking2030.010–2030.410 and the cases construing those sections. other persons or organizations, unless the information is equally available to the asking party.(c) These form interrogatories do not change existing law relatingto interrogatories nor do they affect an answering party’s right (e) Whenever an interrogatory may be answered byto assert any privilege or make any objection. referring to a document, the document may be attached as an exhibit to the response and referred to in theresponse. If the document has more than oneSec. 2. Instructions to the Asking Party page, refer to the page and section where the answer to the interrogatory can be found.(a) These form interrogatories are designed for optional use byparties in employment cases. (Separate sets ofinterrogatories, Form Interrogatories (form FI-120) and Form (f)Whenever an address and telephone number for theInterrogatories—Economic Litigation (form FI-129) may also same person are requested in more than onebe used where applicable in employment cases.) interrogatory, you are required to furnish them in(b) Insert the names of the EMPLOYEE and EMPLOYER to answering only the first interrogatory asking for thatwhom these interrogatories apply in the definitions in sections information.4(d) and (e) below. (g) If you are asserting a privilege or making an objection to(c) Check the box next to each interrogatory that you want the an interrogatory, you must specifically assert theanswering party to answer. Use care in choosing those privilege or state the objection in your written response.interrogatories that are applicable to the case. (h) Your answers to these interrogatories must be verified,(d) The interrogatories in section 211.0, Loss of dated, and signed. You may wish to use the followingIncome Interrogatories to Employer, should not be used form at the end of your answers:until the employer has had a reasonable opportunity to I declare under penalty of perjury under the laws of theconduct an investigation or discovery of the employee’s State of California that the foregoing answers are trueinjuries and damages. and correct.(e) Additional interrogatories may be attached. Sec. 3. Instructions to the Answering Party (DATE)(SIGNATURE)(a) You must answer or provide another appropriate response to Sec. 4. Definitionseach interrogatory that has been checked below. Words in BOLDFACE CAPITALS in these interrogatories(b) As a general rule, within 30 days after you are served with are defined as follows:these interrogatories, you must serve your responses on the (a) PERSON includes a natural person, firm, association,asking party and serve copies of your responses on all other organization, partnership, business, trust, limited liabilityparties to the action who have appeared. See Code of Civil company, corporation, or public entity.Procedure sections 2030.260–2030.270 for details. Page 1 of 8Form Approved for Optional Use Code of Civil Procedure,Judicial Council of California §§ 2030.010–2030.410, 2033.710DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES –EMPLOYMENT LAW electronic form  2005 WWW.LawCA.com Law Publishers DISC-002(b) YOU OR ANYONE ACTING ON YOUR BEHALF includes Sec. 5. Interrogatoriesyou, your agents, your employees, your insurance The following interrogatories for employment law cases havecompanies, their agents, their employees, your attorneys, been approved by the Judicial Council under Code of Civilyour accountants, your investigators, and anyone else acting Procedure section 2033.710:on your behalf. CONTENTS(c) EMPLOYMENT means a relationship in which an 200.0 Contract FormationEMPLOYEE provides services requested by or on behalf of 201.0 Adverse Employment Actionan EMPLOYER, other than an independent contractor 202.0 Discrimination Interrogatories to Employeerelationship. 203.0 Harassment Interrogatories to Employee(d) EMPLOYEE means a PERSON who provides services in an 204.0 Disability DiscriminationEMPLOYMENT relationship and who is a party to this lawsuit. 205.0 Discharge in Violation of Public PolicyFor purposes of these interrogatories, EMPLOYEE refers to 206.0 Defamation(insert name): 207.0 Internal Complaints 208.0 Governmental Complaints 209.0 Other Employment Claims by Employee or Against(If no name is inserted, EMPLOYEE means all such EmployerPERSONS.) 210.0 Loss of income Interrogatories to Employee(e) EMPLOYER means a PERSON who employs an 211.0 Loss of income Interrogatories to EmployerEMPLOYEE to provide services in an EMPLOYMENT 212.0 Physical, Mental, or Emotional Injuries—relationship and who is a party to this lawsuit. For purposes of Interrogatories to Employeethese interrogatories, EMPLOYER refers to (insert name): 213.0 Other Damages Interrogatories to Employee 214.0 Insurance 215.0 Investigation(If no name is inserted, EMPLOYER means all such 216.0 Denials and Special or Affirmative DefensesPERSONS.) 217.0 Response to Request for Admissions(f) ADVERSE EMPLOYMENT ACTION means anyTERMINATION, suspension, demotion, reprimand, loss of 200.0 Contract Formationpay, failure or refusal to hire, failure or refusal to promote, orother action or failure to act that adversely affects the 200.1 Do you contend that the EMPLOYMENT EMPLOYEE’S rights or interests and which is alleged in the relationship was at “at will”? If so:PLEADINGS. (a) state all facts upon which you base this(g) TERMINATION means the actual or constructive termination contention;of employment and includes a discharge, firing, layoff, (b)state the name, ADDRESS, and telephoneresignation, or completion of the term of the employment number of each PERSON who has knowledgeagreement. of those facts; and(h) PUBLISH means to communicate orally or in writing to (c)identify all DOCUMENTS that support youranyone other than the plaintiff. This includes communications contention.by one of the defendant’s employees to others. (Kelly v.General Telephone Co. (1982) 136 Cal.App.3d 278, 284.) 200.2 Do you contend that the EMPLOYMENT(i) PLEADINGS means the original or most recent amended relationship was not “at will”? If so:version of any complaint, answer, cross-complaint, or answer (a) state all facts upon which you base thisto cross-complaint. contention;(b)state the name, ADDRESS, and telephone(j) BENEFIT means any benefit from an EMPLOYER, includingan “employee welfare benefit plan” or employee pension number of each PERSON who has knowledgebenefit plan” within the meaning of Title 29 United States of those facts; andCode section 1002(1) or (2) or ERISA. (c)identify all DOCUMENTS that support your contention.(k) HEALTH CARE PROVIDER includes any PERSON referred to in Code of Civil Procedure section 667.7(e)(3). 200.3 Do you contend that the EMPLOYMENT (l) DOCUMENT means a writing, as defined in Evidence Code relationship was governed by anysection 250, and includes the original or a copy of agreement—written, oral, or implied? If so:handwriting, typewriting, printing, photostats, photographs, (a) state all facts upon which you base thiselectronically stored information, and every other means of contention;recording upon any tangible thing and form of communicating (b)state the name, ADDRESS, and telephoneor representation, including letters, words, pictures, sounds, number of each PERSON who has knowledgeor symbols, or combinations of them. of those facts; and(m) ADDRESS means the street address, including the city, state, (c)identify all DOCUMENTS that support your and zip code. contention.Page 2 of 8FI- DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES–EMPLOYMENT LAW DISC-002 200.4 Was any part of the parties’ EMPLOYMENT 201.2 Are there any facts that would support the relationship governed in whole or in part by any EMPLOYEE’S TERMINATION that were firstwritten rules, guidelines, policies, or procedures discovered after the TERMINATION? If so:established by the EMPLOYER? If so, for each (a) state the specific facts;DOCUMENT containing the written rules, (b) state when and how EMPLOYER first learned ofguidelines, policies, or procedures: each specific fact;(a)state the date and title of the DOCUMENT and (c)state the name, ADDRESS, and telephone number ofa general description of its contents; each PERSON who has knowledge of the specific(b) state the manner in which the DOCUMENT was facts; andcommunicated to employees; and (d)identify all DOCUMENTS that evidence these specific(c) state the manner, if any, in which employees facts.acknowledged either receipt of the DOCUMENT or knowledge of its contents. 201.3 Were there any other ADVERSE EMPLOYMENT ACTIONS, including (the asking party should list the 200.5 Was any part of the parties’ EMPLOYMENT ADVERSE EMPLOYMENT ACTIONS): relationship covered by one or more collective bargaining agreements or memorandums of understanding between the EMPLOYER (or an association of employers) and any labor union or employee association? If so, for each collective bargaining agreement or memorandum of understanding, state:(a) the names and ADDRESSES of the parties to the If so, for each action, provide the following:collective bargaining agreement or memorandum of(a) all reasons for each ADVERSE EMPLOYMENTunderstanding; ACTION;(b)the beginning and ending dates, if applicable, of the (b)the name, ADDRESS, and telephone number ofcollective bargaining agreement or memorandum of each PERSON who participated in making eachADVERSE EMPLOYMENT ACTION decision;understanding; and(c)which parts of the collective bargaining agreement or (c)the name, ADDRESS, and telephone numbermemorandum of understanding, if any, govern (1) of each PERSON who provided any informationany dispute or claim referred to in the PLEADINGS relied upon in making each ADVERSE EMPLOYMENT ACTION decision; andand (2) the rules or procedures for resolving anydispute or claim referred to in the PLEADINGS. (d)the identity of all DOCUMENTS relied upon in making each ADVERSE EMPLOYMENT 200.6 Do you contend that the EMPLOYEE and the ACTION decision. EMPLOYER were in a business relationship otherthan an EMPLOYMENT relationship? If so, for each 201.4 Was the TERMINATION or any otherrelationship: ADVERSE EMPLOYMENT ACTIONS referred to in(a) state the names of the parties to the relationship; Interrogatories 201.1 through 201.3 based in whole or in(b) identify the relationship; and part on the EMPLOYEE'S job performance? If so, for each(c) state all facts upon which you base your contention action:that the parties were in a relationship other than an (a)identify the ADVERSE EMPLOYMENT ACTION;EMPLOYMENT relationship. (b)identify the EMPLOYEE'S specific job performance that played a role in that ADVERSE EMPLOYMENT ACTION;201.0 Adverse Employment Action (c)identify any rules, guidelines, policies, or 201.1 Was the EMPLOYEE involved in a TERMINATION? procedures that were used to evaluate the If so: EMPLOYEE’S specific job performance;(a) state all reasons for the EMPLOYEE’S (d)state the names, ADDRESSES, and telephoneTERMINATION; numbers of all PERSONS who had responsibility for(b) state the name, ADDRESS, and telephone number of evaluating the specific job performance of theeach PERSON who participated in the EMPLOYEE;TERMINATION decision; (e)state the names, ADDRESSES, and telephone(c) state the name, ADDRESS, and telephone number of numbers of all PERSONS who have knowledge of theeach PERSON who provided any information relied EMPLOYEE'S specific job performance that played aupon in the TERMINATION decision; and role in that ADVERSE EMPLOYMENT ACTION; and(d)identify all DOCUMENTS relied upon in the (f)describe all warnings given with respect to theTERMINATION decision. EMPLOYEE’S specific job performance.Page 3 of 8DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES–EMPLOYMENT LAW DISC-002 201.5 Was any PERSON hired to replace the (c)identify each characteristic (for example, gender, EMPLOYEE after the EMPLOYEE’S race, age, etc.) on which you base your claim ofTERMINATION or demotion? If so, state the harassment;PERSON'S name, job title, qualifications, (d)state all facts upon which you base yourADDRESS and telephone number, and the contention that you were unlawfully harassed;date the PERSON was hired. (e)state the name, ADDRESS, and telephone number of each PERSON with knowledge of those facts; and 201.6 Has any PERSON performed any of the (f)identify all DOCUMENTS evidencing those facts. EMPLOYEE’S former job duties after theEMPLOYEE’S TERMINATION or demotion? If so: 204.0 Disability Discrimination (a)state the PERSON’S name, job title, ADDRESS, and telephone number; 204.1 Name and describe each disability alleged in the(b) identify the duties; and PLEADINGS.(c)state the date on which the PERSON started toperform the duties. 204.2 Does the EMPLOYEE allege any injury or illness that arose out of or in the course of EMPLOYMENT ? 201.7 If the ADVERSE EMPLOYMENT ACTION involved If so, state: the failure or refusal to select the EMPLOYEE (for (a)the nature of such injury or illness;example, for hire, promotion, transfer, or training), was (b)how such injury or illness occurred;any other PERSON selected instead? If so, for each (c)the date on which such injury or illnessADVERSE EMPLOYMENT ACTION, state the name, occurred;ADDRESS, and telephone number of each PERSON (d)whether EMPLOYEE has filed a workers’selected; the date the PERSON was selected; and the compensation claim. If so, state the date andreason the PERSON was selected instead of the outcome of the claim; andEMPLOYEE. (e)whether EMPLOYEE has filed or appliedfor disability benefits of any type. If so, state the202.0 Discrimination—Interrogatories to Employee date, identify the nature of the benefits applied for, and the outcome of any such application. 202.1 Do you contend that any ADVERSE EMPLOYMENT ACTIONS against you were 204.3 Were there any communications between thediscriminatory? If so: EMPLOYEE (or the EMPLOYEE’S HEALTH CARE(a)identify each ADVERSE EMPLOYMENT PROVIDER) and the EMPLOYER about the type orACTION that involved unlawful discrimination; extent of any disability of EMPLOYEE? If so:(b) identify each characteristic (for example, gender, (a)state the name, ADDRESS, and telephonerace, age, etc.) on which you base your claim or number of each person who made or receivedclaims of discrimination; the communications;(c) state all facts upon which you base each claim (b)state the name, ADDRESS, and telephoneof discrimination; number of each PERSON who witnessed the(d)state the name, ADDRESS, and telephone number of communications;each PERSON with knowledge of those facts; and (c)describe the date and substance of the(e) identify all DOCUMENTS evidencing those facts. communications; and(d)identify each DOCUMENT that refers to the 202.2 State all facts upon which you base your contention communications. that you were qualified to perform any job which youcontend was denied to you on account of unlawful 204.4 Did the EMPLOYER have any informationdiscrimination. about the type, existence, or extent of any disability ofEMPLOYEE other than from communications with the203.0 Harassment—Interrogatories to Employee EMPLOYEE or the EMPLOYEE’S HEALTH CARE PROVIDER? If so, state the sources and substance of 203.1 Do you contend that you were unlawfully harassed in that information and the name, ADDRESS, and your employment? If so: telephone number of each PERSON who provided or(a) state the name, ADDRESS, telephone number, and received the information.employment position of each PERSON whom youcontend harassed you; 204.5 Did the EMPLOYEE need any(b) for each PERSON whom you contend harassed you, accommodation to perform any function of thedescribe the harassment; EMPLOYEE’S job position or need a transfer to another position as an accommodation? If so,describe the accommodations needed.Page 4 of 8DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES– EMPLOYMENT LAW DISC-002 204.6 Were there any communications between the (d)state whether, at the time the statement was EMPLOYEE (or the EMPLOYEE’S HEALTH CARE PUBLISHED, the PERSON who PUBLISHED thePROVIDER) and the EMPLOYER about any possible statement believed it to be true; andaccommodation of EMPLOYEE ? If so, for each (e) state all facts upon which the PERSON whocommunication: published the statement based the belief that it was(a) state the name, ADDRESS, and telephone true.number of each PERSON who made orreceived the communication; 206.2 State the name and ADDRESS of each agent or(b) state the name, ADDRESS, and telephone employee of the EMPLOYER who responded to anynumber of each PERSON who witnessed the inquiries regarding the EMPLOYEE after thecommunication; EMPLOYEE’S TERMINATION.(c)describe the date and substance of thecommunication; and 206.3 State the name and ADDRESS of the recipient(d) identify each DOCUMENT that refers to the and the substance of each post-TERMINATIONcommunication. statement PUBLISHED about EMPLOYEE by any agent or employee of EMPLOYER . 204.7 What did the EMPLOYER consider doing to accommodate the EMPLOYEE ? For each 207.0 Internal Complaintsaccommodation considered:(a) describe the accommodation considered; 207.1 Were there any internal written policies or(b) state whether the accommodation was offered to the regulations of the EMPLOYER that apply to the makingEMPLOYEE; of a complaint of the type that is the subject matter of(c)state the EMPLOYEE’S response; or this lawsuit? If so:(d) if the accommodation was not offered, state all the (a) state the title and date of each DOCUMENTreasons why this decision was made; containing the policies or regulations and a(e) state the name, ADDRESS, and telephone number of general description of the DOCUMENT’Seach PERSON who on behalf of EMPLOYER made contents;any decision about what accommodations, if any, to (b)state the manner in which the DOCUMENT wasmake for the EMPLOYEE; and communicated to EMPLOYEES;(f) state the name, ADDRESS, and telephone number of (c)state the manner, if any, in which EMPLOYEESeach PERSON who on behalf of the EMPLOYER acknowledged receipt of the DOCUMENT ormade or received any communications about what knowledge of its contents, or both;accommodations, if any, to make for the (d)state, if you contend that the EMPLOYEE failedEMPLOYEE. to use any available internal complaint205.0 Discharge in Violation of Public Policy procedures, all facts that support that contention; and 205.1 Do you contend that the EMPLOYER took any (e)state, if you contend that the EMPLOYEE’S ADVERSE EMPLOYMENT ACTION against you in failure to use internal complaint procedures wasviolation of public policy? If so: excused, all facts why the EMPLOYEE’S use of(a) identify the constitutional provision, statute, the procedures was excused.regulation, or other source of the public policy thatyou contend was violated; and 207.2 Did the EMPLOYEE complain to the(b) state all facts upon which you base your contention EMPLOYER about any of the unlawful conductthat the EMPLOYER violated public policy. alleged in the PLEADINGS? If so, for each complaint:206.0 Defamation (a) state the date of the complaint;(b) state the nature of the complaint; 206.1 Did the EMPLOYER'S agents or employees (c)state the name and ADDRESS of each PUBLISH any of the allegedly defamatory statements PERSON to whom the complaint was made;identified in the PLEADINGS ? If so, for each (d)state the name, ADDRESS, telephone number,statement: and job title of each PERSON who investigated(a) identify the PUBLISHED statement; the complaint;(b) state the name, ADDRESS, telephone number, and (e)state the name, ADDRESS , telephone number,job title of each person who PUBLISHED the and job title of each PERSON who participatedstatement; in making decisions about how to conduct the(c)state the name, ADDRESS, and telephone number of investigation;each person to whom the statement wasPUBLISHED;Page 5 of 8DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES–EMPLOYMENT LAW DISC-002(f)state the name, ADDRESS, telephone number, (d)state the name, ADDRESS, telephone number, andand job title of each PERSON who was job title of each PERSON who was interviewed orinterviewed or who provided an oral or written who provided an oral or written statement as part ofstatement as part of the investigation of the complaint; the investigation.(g) state the nature and date of any action taken in 209.0 Other Employment Claims by Employee orresponse to the complaint; Against Employer(h)state whether the EMPLOYEE who made thecomplaint was made aware of the actions taken 209.1 Except for this action, in the past 10 years hasby the EMPLOYER in response to the the EMPLOYEE filed a civil action against anycomplaint, and, if so, state how and when; employer regarding the EMPLOYEE’S employment? If(i)identify all DOCUMENTS relating to the so, for each civil action:complaint, the investigation, and any action (a)state the name, ADDRESS, and telephonetaken in response to the complaint; and number of each employer against whom the(j) state the name, ADDRESS, and telephone action was filed;number of each PERSON who has knowledge (b)state the court, names of the parties, and caseof the EMPLOYEE’S complaint or the number of the civil action;EMPLOYER'S response to the complaint. (c)state the name, ADDRESS , and telephone number of any attorney representing the208.0 Governmental Complaints EMPLOYEE; and(d)state whether the action has been resolved 208.1 Did the EMPLOYEE file a claim, complaint, or charge or is pending. with any governmental agency that involved any of thematerial allegations made in the PLEADINGS? If so, for 209.2 Except for this action, in the past 10 years haseach claim, complaint, or charge: any employee filed a civil action against the(a)state the date on which it was filed; EMPLOYER regarding his or her employment?(b) state the name and ADDRESS of the agency with If so, for each civil action:which it was filed; (a)state the name, ADDRESS, and telephone(c) state the number assigned to the claim, complaint, or number of each employee who filed the action;charge by the agency; (b)state the court, names of the parties, and case(d) state the nature of each claim, complaint, or charge number of the civil action;made; (c)state the name, ADDRESS, and telephone(e) state the date on which the EMPLOYER was number of any attorney representing thenotified of the claim, complaint, or charge; EMPLOYER; and(f)state the name, ADDRESS, and telephone number of (d)state whether the action has been resolved orall PERSONS within the governmental agency with is pending.whom the EMPLOYER has had any contact orcommunication regarding the claim, complaint, or 210.0 Loss of Income—Interrogatories to Employeecharge;(g) state whether a right to sue notice was issued and, if 210.1 Do you attribute any loss of income, benefits,so, when; and or earning capacity to any ADVERSE(h) state whether any findings or conclusions regarding EMPLOYMENT ACTION? (If your answer is “no,” dothe complaint or charge have been made, and, if so, not answer Interrogatories 210.2 through 210.6.)the date and description of the agency’s findings orconclusions. 210.2 State the total amount of income, benefits, or earning capacity you have lost to date and how the amount was calculated. 208.2 Did the EMPLOYER respond to any claim, complaint, or charge identified in Interrogatory 208.1? If so,for each claim, complaint, or charge: 210.3 Will you lose income, benefits, or earning(a) state the nature and date of any investigation done or capacity in the future as a result of any ADVERSEany other action taken by the EMPLOYER in EMPLOYMENT ACTION? If so, state the total amountresponse to the claim, complaint, or charge: of income, benefits, or earning capacity you expect to(b)state the name, ADDRESS, telephone number, and lose, and how the amount was calculated.job title of each person who investigated the claim,complaint, or charge; 210.4 Have you attempted to minimize the amount of(c) state the name, ADDRESS, telephone number, and your lost income? If so, describe how; if not,job title of each PERSON who participated in making explain why not.decisions about how to conduct the investigation; andPage 6 of 8DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES–EMPLOYMENT LAW DISC-002 210.5 Have you purchased any benefits to replace 212.0 Physical, Mental, or Emotional Injuries— any benefits to which you would have been entitled if Interrogatories to Employeethe ADVERSE EMPLOYMENT ACTION had notoccurred? If so, state the cost for each benefit 212.1 Do you attribute any physical, mental, or emotionalpurchased. injuries to the ADVERSE EMPLOYMENT ACTION? (If your answer is “no,” do not answer Interrogatories 212.2 210.6 Have you obtained other employment since any through 212.7.) ADVERSE EMPLOYMENT ACTION? If so, for each newemployment: 212.2 Identify each physical, mental, or emotional(a) state when the new employment commenced; injury that you attribute to the ADVERSE(b) state the hourly rate or monthly salary for the EMPLOYMENT ACTION and the area of your bodynew employment; and affected.(c)state the benefits available from the newemployment. 212.3 Do you still have any complaints of physical, mental, or emotional injuries that you attribute to the211.0 Loss of Income —Interrogatories to Employer ADVERSE EMPLOYMENT ACTION? If so, for each[See instruction 2(d).] complaint state:(a)a description of the injury; 211.1 Identify each type of BENEFIT to which the (b)whether the complaint is subsiding, remaining EMPLOYEE would have been entitled, from the date the same, or becoming worse; andof the ADVERSE EMPLOYMENT ACTION to the (c)the frequency and duration.present, if the ADVERSE EMPLOYMENT ACTIONhad not happened and the EMPLOYEE had 212.4 Did you receive any consultation or examinationremained in the same job position. For each type of (except from expert witnesses covered by Code of Civilbenefit, state the amount the EMPLOYER would Procedure section 2034) or treatment from a HEALTHhave paid to provide the benefit for the EMPLOYEE CARE PROVIDER for any injury you attribute to theduring this time period and the value of the BENEFIT ADVERSE EMPLOYMENT ACTION? If so, for eachto the EMPLOYEE. HEALTH CARE PROVIDER state:(a)the name, ADDRESS, and telephone number; 211.2 Do you contend that the EMPLOYEE has not made (b)the type of consultation, examination, or reasonable efforts to minimize the amount of the treatment provided;EMPLOYEE’S lost income? If so: (c)the dates you received consultation,(a) describe what more EMPLOYEE should have done; examination, or treatment; and(b) state the names, ADDRESSES, and telephone (d)the charges to date.numbers of all PERSONS who have knowledge ofthe facts that support your contention; and 212.5 Have you taken any medication, prescribed or(c)identify all DOCUMENTS that support your not, as a result of injuries that you attribute to thecontention and state the name, ADDRESS, and ADVERSE EMPLOYMENT ACTION? If so, for eachtelephone number of the PERSON who has each medication state:DOCUMENT. (a)the name of the medication; 211.3 Do you contend that any of the lost income claimed (b)the name, ADDRESS and telephone number of by the EMPLOYEE, as disclosed in discovery thus far the PERSON who prescribed or furnished it;in this case, is unreasonable or was not caused by (c)the date prescribed or furnished;the ADVERSE EMPLOYMENT ACTION? If so: (d)the dates you began and stopped taking it; and(a) state the amount of claimed lost income that you (e)the cost to date.dispute;(b) state all facts upon which you base your contention; 212.6 Are there any other medical services not(c) state the names, ADDRESSES, and telephone previously listed in response to interrogatory 212.4 (fornumbers of all PERSONS who have knowledge of example, ambulance, nursing, prosthetics) that youthe facts; and received for injuries attributed to the ADVERSE(d) identify all DOCUMENTS that support your EMPLOYMENT ACTION? If so, for each service state:contention and state the name, ADDRESS, and (a)the nature;telephone number of the PERSON who has each (b)the date;DOCUMENT. (c)the cost; and(d) the name, ADDRESS, and telephone number of each HEALTH CARE PROVIDER . Page 7 of 8 DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES– EMPLOYMENT LAW DISC- 002 212.7 Has any HEALTH CARE PROVIDER advised 215.0 Investigation that you may require future or additional treatment forany injuries that you attribute to the ADVERSE 215.1 Have YOU OR ANYONE ACTING ON YOUREMPLOYMENT ACTION? If so, for each injury state: BEHALF interviewed any individual concerning the(a)the name and ADDRESS of each HEALTH ADVERSE EMPLOYMENT ACTION? If so, for eachCARE PROVIDER; individual state:(b)the complaints for which the treatment was advised; (a)the name, ADDRESS, and telephone number ofand the individual interviewed;(c)the nature, duration, and estimated cost of the (b)the date of the interview; andtreatment. (c)the name, ADDRESS, and telephone number of the PERSON who conducted the interview.213.0 Other Damages—Interrogatories to Employee 215.2 Have YOU OR ANYONE ACTING ON YOUR213.1 Are there any other damages that you attribute to BEHALF obtained a written or recorded statement from the ADVERSE EMPLOYMENT ACTION? If so, for any individual concerning the ADVERSE EMPLOYMENTeach item of damage state: ACTION? If so, for each statement state:(a) the nature; (a)the name, ADDRESS, and telephone number of(b)the date it occurred; the individual from whom the statement was(c)the amount; and obtained;(d)the name, ADDRESS , and telephone number of (b)the name, ADDRESS, and telephone number ofeach PERSON who has knowledge of the the individual who obtained the statement;nature or amount of the damage. (c)the date the statement was obtained; and(d) the name, ADDRESS, and telephone number of 213.2 Do any DOCUMENTS support the existence or each PERSON who has the original statement or amount of any item of damages claimed in Interrogatory a copy.213.1 ? If so, identify the DOCUMENTS and state the name,ADDRESS, and telephone number of the PERSON who 216.0 Denials and Special or Affirmative Defenseshas each DOCUMENT . 216.1 Identify each denial of a material allegation 214.0 Insurance and each special or affirmative defense in yourPLEADINGS and for each: 214.1 At the time of the ADVERSE EMPLOYMENT (a)state all facts upon which you base the denial or ACTION, was there in effect any policy of insurance special or affirmative defense;through which you were or might be insured in any (b)state the names, ADDRESSES, and telephonemanner for the damages, claims, or actions that have numbers of all PERSONS who have knowledgearisen out of the ADVERSE EMPLOYMENT ACTION? of those facts; andIf so, for each policy state: (c)identify all DOCUMENTS and all other tangible(a) the kind of coverage; things, that support your denial or special or(b)the name and ADDRESS of the insurance affirmative defense, and state the name,company; ADDRESS, and telephone number of the(c) the name, ADDRESS , and telephone number of PERSON who has each DOCUMENT.each named insured;(d)the policy number; 217.0 Response to Request for Admissions(e) the limits of coverage for each type of coveragecontained in the policy; 217.1 Is your response to each request for admission(f) whether any reservation of rights or controversy served with these interrogatories an unqualifiedor coverage dispute exists between you and the admission? If not, for each response that is not aninsurance company; and unqualified admission:(g) the name, ADDRESS , and telephone number of (a)state the number of the request;the custodian of the policy. (b)state all facts upon which you base your response; 214.2 Are you self-insured under any statute for the (c)state the names, ADDRESSES, and telephone damages, claims, or actions that have arisen out of the numbers of all PERSONS who have knowledgeADVERSE EMPLOYMENT ACTION? If so, specify the of those facts; andstatute. (d)identify all DOCUMENTS and other tangible things that support your response and state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT or thing.Page 8 of 8DISC-002 [Rev. January 1, 2007] FORM INTERROGATORIES– EMPLOYMENT LAW