Fill and Sign the Hereinafter Referred to Simply as the Occurrence Form

- 1 - Add Case Style MOTOR VEHICLE INTERROGATORIES TO PLAINTIFFS COMES NOW Defendant, __________________________ and hereby propounds the following interrogatories to Plaintiff, _________________________, and requests Plaintiff to answer these interrogatories in the time and manner as provided for by the applicable disc overy rules of the State of Maine. Defendant gives notice that these interrogatories are continuing in nature and are to be supplemented during the course of this litigation in accordance wi th law. Answers are due within _____ days of service of these interrogatories. INTERROGATORY NO. 1: State your full name, as well as your current residence address, date of birth, marital status, driver's license number and issuing state, and social securit y number. 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 (hereinafter referred to simply as the occurrence). 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 cha rges filed against you, whether you pleaded guilty thereto and the final disposition. INTERROGATORY NO. 5: Describe the personal injuries sustained by you as a result of the occurrence. INTERROGATORY NO. 6: With regard to your injuries, state: (a) The name and address of each attending physician and/or health care professional; (b) The name and address of each consulting physician and/or other health care professional; (c) The name and address of each person and/or laboratory taking any X-ray, MRI and/or other radiological tests of you; (d) The date or inclusive dates on which each of them rendered you service; (e) The amounts to date of their respective bills for services; and (f) From which of them you have written reports. INTERROGATORY NO. 7: As the result of your personal injuries, were you a patient or outpatient in any hospital and/or clinic? If so, state the names and addresses of all hospita ls and/or clinics, the amounts of their respective bills and the date or inclusive dates of the i r services. - 2 - INTERROGATORY NO. 8: As the result of your personal injuries, were you unable to work? If so, state: (a) The name and address of your employer, if any, at the time of the occurrence, your wage and/or salary, and the name of your supervisor and/or foreperson; (b) The date or inclusive dates on which you were unable to work; (c) The amount of wage and/or income loss claimed by you; and (d) The name and address of your present employer and your wage and/or salary. INTERROGATORY NO. 9: State any and all other expenses and/or losses you claim as a resul t of the occurrence. As to each expense and/or loss, state the date or dates it was incurred, the name of the person, firm and/or company to whom such amounts are owed, whether the expense and/or loss in question has been paid and, if so, by whom it was so paid, and describe the reason and/or purpose for each expense and/or loss. INTERROGATORY NO. 10: Had you suffered any personal injury or prolonged, serious and/or chronic illness prior to the date of the occurrence? If so, state when and how you were injured and/or ill, where you were injured and/or ill, describe the injuries and/or illness suffered, and state the name and address of each physician, or other health care professional, hospital and/or clinic rendering you treatment for each injury and/or chronic illness. INTERROGATORY NO. 11: Are you claiming any psychiatric, psychological and/or emotional injuries as a result of this occurrence? If so, state: (a) The name of any psychiatric, psychological and/or emotional injury claimed, and the name and address of each psychiatrist, physician, psychologist, therapist or other health care professional rendering you treatment for each injury; (b) Whether you had suffered any psychiatric, psychological and/or emotional injury prior to the date of the occurrence; and (c) If the answer to (b) is in the affirmative, please state when and the nature of any psychiatric, psychological and/or emotional injury, and the name and address of each psychiatrist, physician, psychologist, therapist or other health care professional rendering you treatment for each injury INTERROGATORY NO. 12: Have you suffered any personal injury or prolonged, serious and/or chronic illness since the date of the occurrence? If so, state when you were injured and/or ill, where and how you were injured and/or ill, describe the injuries and/or the illness suffered, and state the name and address of each physician or other health care professional, hospital and/or clinic rendering you treatment for each injury and/or chronic illness. INTERROGATORY NO. 13: Have you ever filed any other suits for your own personal injuries? If so, state the nature of the injuries claimed, the courts and the captions in which filed, the y ears filed, and the titles and docket numbers of the suits. - 3 - INTERROGATORY NO. 14: Have you ever filed a claim for and/or received any workers' compensation benefits? If so, state the name and address of the employer against whom you fi led for and/or received benefits, the date of the alleged accident or accidents, the description of the alleged accident or accidents, the nature of your injuries claimed and the name of the insurance company, if any, who paid any such benefits. INTERROGATORY NO. 15: 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, occupation and employer of the person taking them. INTERROGATORY NO. 16: 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 to the manner in which the occurrence complained of occurred? If the answer to this interrogatory is in the affirmative, state t he 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. 17: Do you know of any statements made by any person relating to the occurrence? If so, give the name and address of each such witness, the date of the statement , and state whether such statement was written and/or oral. INTERROGATORY NO. 18: 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 alcoholic beverages. INTERROGATORY NO. 19: 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 c onviction, 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. 20: 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 said drug or medication. - 4 - INTERROGATORY NO. 21: Have you received any payment and/or other consideration from any source in compensation for the injuries alleged in your complaint? If your answer is in the affirmative, state: (a) The amount of such payment and/or other consideration received; (b) The name of the person, firm, insurance company and/or corporation making such payment or providing other consideration and the reason for the payment and/or other consideration; and (c) Whether there are any documents evidencing such payment and/or other consideration received. INTERROGATORY NO. 22: State the name and address of the registered owner of each vehicle involved in the occurrence. INTERROGATORY NO. 23: 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. 24: What was the purpose and/or use for which the vehicle was being operated at the time of the occurrence? INTERROGATORY NO. 25: 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. 26: Please provide the name and address of each witness who will testify at trial and state the subject of each witness’ testimony. INTERROGATORY NO. 27: Please 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 basis therefor, including reports of the witness, if any; (c) The qualifications of each opinion witness, including a curriculum vitae and/or resume, if any; and (d) The identity of any written reports of the opinion witness regarding this occurrence. INTERROGATORY NO. 28: 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 the injuries and damages claimed to have resulted therefrom. INTERROGATORY NO. 29: 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, spec ify the legal basis for the claim. - 5 - DATED this the ________ day of _____________________________, 20_____. Respectfully Submitted, _____________________________ Signature Name Address City, 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___. _____________________________________ Signature