Fill and Sign the Interrogatories Personal Injury Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) INTERROGATORIES TO ____________________ Comes now the Plaintiff, ____________ in the above styled cause and desiring the testimony of the Defendant, _____________, propound to said Defendant the following interrogatories to be answered pursuant to Rule ___ of the __________ Rules of Civil Procedure, to wit: 1. Please state your full and complete name, date of birth, social security number and driver’s license number. ANSWER : 2. Please explain how you contend the accident of ________________, that is made the basis of this suit occurred and, with respect to said accident. ANSWER : - 2 - 3. Please state the substance of all conversations between yourself and ____________ regarding the accident that is made the basis of this suit. ANSWER: 4. Please state the name and address of each person known to you to have witnessed the accident of that is made the basis of this suit. ANSWER : 5. List the name and address of each person with whom you have ever discussed this accident, other than your attorney. ANSWER : 6. Have you discussed this accident with any representative at your insurance company? ANSWER : 7. List all auto accidents of any nature of which you are aware that _______________ has ever been involved in either as a driver or as a passenger including the date, the parties involved, and a description of the accident. - 3 - ANSWER: 8. List all moving violations of which you are aware _______________ has ever received, including the date, the location, the nature of the violation, and the disposition. ANSWER : 9. Do you understand these interrogatories are to be answered under oath? ANSWER : Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: CERTIFICATE OF SERVICE - 4 - 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____. _________________________________ Plaintiff