Fill and Sign the Defendant Plaintiff Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) FIRST INTERROGATORIES AND REQUESTS FOR PRODUCTION TO THE PLAINTIFF BY THE DEFENDANT Comes now _______________, Inc., Defendant in the above styled action, and, pursuant to the _______________ Rules of Civil Procedure, propounds the following Interrogatories and Requests for Production to the Plaintiff: 1. Please state your name, date of birth, social security number and home address. ANSWER: 2. Have you ever filed any other lawsuit or claim for damages for any personal injuries, illness or disability? If so, what was the nature of the claim and the final result? ANSWER: 3. Describe fully and completely how the incident made the basis of this suit occurred, stating in your answer all events relating thereto in their sequential order. - 2 - ANSWER:4. As to the condition which you contend caused the accident, state:(a) A description of the condition that you allege made the premises dangerous; (b) Each fact which indicates the length existed prior to the accident; (c) Each fact which tends to show that the have known of the condition; (d) Each act which the Defendant failed to perform to make the premises reasonably safe for use; (e) The time that you first became aware of such condition in relation to your accident. ANSWER: 5. State the name and address of each physician, medical practitioner, hospital or health care provider you consulted as a result of the alleged occurrence, setting forth in detail as to each the date of examination or treatment and the diagnosis and prognosis made by each. ANSWER: 6. If you claim that you were disabled as a result of the accident described in your complaint, state the inclusive dates you claim you were totally or partially di sabled from your normal activities. ANSWER: - 3 - 7. Give an itemized account and attach all documents in your possession reflecting each and every loss, expense and/or damage which you claim was incurred by you, or on your behalf, as a result of the alleged occurrence, including, but not limited to, those losses or expenses which are attributable to hospitals, doctors, nursing, medicines, medical applianc es, and the loss of earning capacity. ANSWER: 8. In your complaint you allege that as a result of _______________' negligence, you were injured. As to this allegation: (a) State each and every fact upon which you rely in support of said allegation attaching any documents upon which you rely; (b) Identify by name, home address, and home telephone number all persons who have personal knowledge of facts material to the issues in this case. ANSWER: 9. In your complaint you allege that as a proximate result of _______________’s wantonness you were injured. As to this allegation: (a) State each and every fact upon which you rely in support of said allegation attaching any documents upon which you rely; (b) Identify by name, home address, and home telephone number all persons who have personal knowledge of facts material to the issues in this case. ANSWER: - 4 - 10. If you had been treated for a physical injury, disease or had been hospitalized prior to this accident, list the nature of treatment and the name and address of the party providing medical treatment to you. ANSWER: 11. With regard to any damages you claim as a result of the accident described i n your complaint, state whether you have received any payments, or if any payments have been made on your behalf by entities other than yourself, including, but not limited to insurance , giving the name of each and the amount of payment provided. ANSWER: 12. If, as a result of the occurrence alleged in your declaration, you lost any earning capacity or any time from your occupation or business or employment, please state as accurately as possible: (a) The full name and address of your employer or your place of business; (b) The average weekly income received by you from your work at thattime; (c) The date on which you resumed work after the alleged occurrence. ANSWER: 13. Have you ever been arrested or convicted of any crime, felony or misdemeanor? If so, please state: (a) The date of the arrest or conviction; - 5 - (b) The crime(s) in which you were accused; (c) The court in which these charges were filed; and (d) The dates of the disposition of any charges or convictions. ANSWER: 14. State whether you noticed any warning signs/cones in the area where your accident occurred. If so, state when you noticed them and where they were located. ANSWER: 15. Identify by name, home address, and home telephone number all persons who have personal knowledge of facts material to the issues in this case, whether favorable or unfavorable to your position. ANSWER: 16. State the name, address and identity of each person whom you expect to call as an expert witness at the trial, state the substance of the facts and opinions to whi ch each such expert is expected to testify and give the summary of the grounds for each opinion of each such expert. ANSWER: 17. If any photographs have been taken of the scene of the occurrence referred to in your complaint, please state the name, address, telephone number and occupation of the photographer. If any photographs are in your possession at this time, please attach a copy of such photographs to your responses. - 6 - ANSWER:18. State whether or not you ever made or gave any statement, whether oral or in writing to anyone regarding the happening of the alleged occurrence; as to each such statem ent, state the name, address and telephone number of each person to whom you made or gave that state ment, and the date and substance of each statement. ANSWER: 19. Please state in detail all conversations you had or have had with any representat ive or employee of the Defendant, _______________, Inc., at the time of the incident made the basis of this suit or at any time thereafter. ANSWER: ____________________ Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 7 - CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. _________________________________