Fill and Sign the Coverage Property Damage and Medical Payment Coverage Form

- 1 - Add Case Style MOTOR VEHICLE INTERROGATORIES TO DEFENDANTS INTERROGATORY NO. 1: State the full name of the defendant answering, as well as your current residence address, date of birth, marital status, driver's license number and issuing state, and social security number, and, if different, give the full name, as well as the current residence address, date of birth, marital status, driver's license number and issuing state, and social security number of the individual signing these answers. INTERROGATORY NO. 2: State the full name and current residence address of each person who witnessed or claims to have witnessed the occurrence that is the subject of this suit. INTERROGATORY NO. 3: State the full name and current residence address of each person not named in interrogatory No. 2 above who was present and/or claims to have been present at the scene immediately before, at the time of, and/or immediately after the occurrence. INTERROGATORY NO. 4: As a result of the occurrence, were you made a defendant in any criminal or traffic case? If so, state the court, the caption, the case number, the charge or charges filed against you, whether you pleaded guilty thereto and the final disposition. INTERROGATORY NO. 5: Were you the owner and/or driver of the vehicle involved in the occurrence? If so, state whether the vehicle was repaired and, if so, state when, where, by whom, and the cost of the repairs. INTERROGATORY NO. 6: Were you the owner and/or driver of any vehicle involved in the occurrence? If so, state whether you were named or covered under any policy, or policies, of liability insurance effective on the date of the occurrence and, if so, state the name of each such company or companies, the policy number or numbers, the effective period(s) and the maximum liability limits for each person and each occurrence, including umbrella or excess insurance coverage, property damage and medical payment coverage. INTERROGATORY NO. 7: Do you have any information: (a) That any plaintiff was, within the five years immediately prior to the occurrence, confined in a hospital and/or clinic, treated by a physician and/or other health professional, or x-rayed for any reason other than personal injury? If so, state each plaintiff so involved, the name and address of each such hospital and/or clinic, physician, technician and/or other health care professional, the approximate date of such confinement or service and state the reason for such confinement or service; (b)That any plaintiff has suffered any serious personal injury and/or illness prior to the date of the occurrence? If so, state the name of each plaintiff so involved and - 2 - state when, where and how he or she was injured and/or ill and describe the injuries and/or illness suffered; (c) That any plaintiff has suffered any serious personal injury and/or illness since the date of the occurrence? If so, state the name of each plaintiff so involved and state when, where and how he or she was injured and/or ill and describe the injuries and/or illness suffered; (d)That any plaintiff has ever filed any other suit for his or her own personal injuries? If so, state the name of each plaintiff so involved and state the court and caption in which filed, the year filed, the title and docket number of the case.INTERROGATORY NO. 8: Were any photographs, movies and/or videotapes taken of the scene of the occurrence or of the persons and/or vehicles involved? If so, state the date or dates on which such photographs, movies and/or videotapes were taken, the subject thereof, who now has custody of them, and the name, address and occupation and employer of the person taking them. INTERROGATORY NO. 9: Have you (or has anyone acting on your behalf) had any conversations with any person at any time with regard to the manner in which the occurrence complained of occurred, or have you overheard any statements made by any person at any time with regard to the injuries complained of by plaintiff or the manner in which the occurrence complained of occurred? If the answer to this interrogatory is in the affirmative, state the following: (a) The date or dates of such conversations and/or statements; (b)The place of such conversations and/or statements; (c) All persons present for the conversations and/or statements; (d)The matters and things stated by the person in the conversations and/or statements; (e)Whether the conversation was oral, written and/or recorded; and (f)Who has possession of the statement if written and/or recorded. INTERROGATORY NO. 10: Do you know of any statements made by any person relating to the occurrence complained of by the plaintiff? If so, give the name and address of each such witness and the date of the statement, and state whether such statement was written and/or oral. INTERROGATORY NO. 11: Had you consumed any alcoholic beverage within 12 hours immediately prior to the occurrence? If so, state the names and addresses of those from whom it was obtained, where it was consumed, the particular kind and amount of alcoholic beverage so consumed by you, and the names and current residence addresses of all persons known by you to have knowledge concerning the consumption of the alcoholic beverages. - 3 - INTERROGATORY NO. 12: Have you ever been convicted of a misdemeanor involving dishonesty, false statement or a felony? If so, state the nature thereof, the date of the conviction, and the court and the caption in which the conviction occurred. For the purpose of this interrogatory, a plea of guilty shall be considered as a conviction. INTERROGATORY NO. 13: Had you used any drugs or medications within 24 hours immediately prior to the occurrence? If so, state the names and addresses of those from whom it was obtained, where it was used, the particular kind and amount of drug or medication so used by you, and the names and current residence addresses of all persons known by you to have knowledge concerning the use of the drug or medication. INTERROGATORY NO. 14: Were you employed on the date of the occurrence? If so, state the name and address of your employer, and the date of employment and termination, if applicable. If your answer is in the affirmative, state the position, title and nature of your occupational responsibilities with respect to your employment. INTERROGATORY NO. 15: What was the purpose and/or use for which the vehicle was being operated at the time of the occurrence? INTERROGATORY NO. 16: State the names and addresses of all persons who have knowledge of the purpose for which the vehicle was being used at the time of the occurrence. INTERROGATORY NO. 17: State the name and address of the registered owner of each vehicle involved in the occurrence. INTERROGATORY NO. 18: Have you ever had your driver's license suspended or revoked? If so, state whether it was suspended or revoked, the date it was suspended or revoked, the reason for the suspension or revocation, the period of time for which it was suspended or revoked, and the state that issued the license. INTERROGATORY NO. 19: Do you have or have you had any restrictions on your driver's license? If so, state the nature of the restrictions. INTERROGATORY NO. 20: Do you have any medical and/or physical condition which required a physician's report and/or letter of approval in order to drive? If so, state the nature of the medical and/or physical condition, the physician or other health care professional who issued the letter and/or report, and the names and addresses of any physician or other health care professional who treated you for this condition prior to the occurrence. INTERROGATORY NO. 21: State the name and address of any physician, ophthalmologist, optician or other health care professional who performed any eye examination of you within the last five years and the dates of each such examination. INTERROGATORY NO. 22: State the name and address of any physician or other health care professional who examined and/or treated you within the last 10 years and the reason for such examination and/or treatment. - 4 - INTERROGATORY NO. 23: Provide the name and address of each witness who will testify at trial and state the subject of each witness' testimony. INTERROGATORY NO. 24: Provide the name and address of each opinion witness who will offer any testimony and state: (a)The subject matter on which the opinion witness is expected to testify;(b)The conclusions and/or opinions of the opinion witness and the basistherefor, including reports of the witness, if any; (c)The qualifications of each opinion witness, including a curriculumvitae and/or resume, if any; and (d)The identity of any written reports of the opinion witness regarding thisoccurrence.INTERROGATORY NO. 25: List the names and addresses of all other persons (other than yourself and persons heretofore listed) who have knowledge of the facts of the occurrence and/or of the injuries and damages claimed to have resulted therefrom. INTERROGATORY NO. 26: Identify any statements, information and/or documents known to you and requested by any of the foregoing interrogatories which you claim to be work product or subject to any common law or statutory privilege, and with respect to each interrogatory, specify the legal basis for the claim. DATED this the ________ day of _____________________________, 20_____.Respectfully Submitted,_____________________________ SignatureName AddressCity, State, Zip CERTIFICATE OF SERVICE This is to certify that I, _______________, have mailed this day, by U.S. Mail, postage fully prepaid, a copy of the above and foregoing interrogatories to: ___________________________________________________________________________ _________________________ This the ____ day of _______________, 20___. _____________________________________ - 5 -Signature