Fill and Sign the Interrogatories Template 497329957 Form

BEFORE THE ___________ WORKERS’ COMPENSATION COMMISSION CLAIMANT )       ) V. ) EMPLOYER ) NO.       ) ) AND ) ) CARRIER )       )             CLAIMANT'S FIRST SET OF INTERROGATORIES TO EMPLOYER AND CARRIER COMES NOW the Claimant in the above styled and numbered cause, by and through counsel, and propounds the following Interrogatories to the Employer and Carrier in this cause as follows, to-wit: INTERROGATORY NO. 1(A): Please state the dates the Claimant was employed with the Employer. (B) State Claimant's job specification and duties; (C) State Claimant's rate of pay per hour and hours worked each week; (D) State Claimant's gross and net income for the entire period of employment; and (E) State the total amount paid Claimant in the twelve month period preceding the date of injury on or about __________ __, _____. INTERROGATORY NO. 2: Please state the names, addresses, and telephone numbers of any witnesses to the injury which forms the basis of this action and state whether or not oral or written statements have been obtained from these witnesses, the dates thereof, the interviewers of each witness, and the identity of each person in possession of such statement. INTERROGATORY NO. 3: Please state the total amount of medical disbursements paid by the employer for the Claimant's care and treatment. INTERROGATORY NO. 4: Please state the names, addresses and telephone numbers of all physicians who consulted, treated, and/or examined the Claimant on behalf of the Employer and provide the dates of all examinations, the nature of each examination, the treatment rendered, and the cost of each examination. INTERROGATORY NO. 5: If any written or oral statements were obtained from the Claimant, please show the dates thereof, the identity of the interviewer, and the identity of each person in possession of such statements, and the exact detail and substance of such statements. INTERROGATORY NO. 6: If the Employer had Claimant submit to a medical examination prior to his employment, please give the date of the examination, the identity of the physician, and, if a written report was made by the physician, please state the substance of said report. INTERROGATORY NO. 7: Identify each person you will call as an expert witness at the trial of this matter and state the subject matter on which the expert is expected to testify, the substance of the facts and opinions to which he is expected to testify, and provide a summary of the grounds for each such opinion. INTERROGATORY NO. 8: Please state why, if applicable, you allege in No. 1 of your Answer that the alleged injury resulted in no compensable loss of time. INTERROGATORY NO. 9: Please state why you deny that Claimant sustained an injury or occupational disease on or about the date set forth in the Petition to Controvert. If you denied on the basis of anything other than the Petition to Controvert's statement that the injury occurred on the _____ day of __________, ____ instead of the ____________, ____, as shown in the medical records, please state your reason for your denial in detail. INTERROGATORY NO. 10: Please state why you deny in Nos. 7, 8, and 9 of your Answer that the Claimant was temporarily disabled or is permanently disabled and/or that Claimant sustained a loss of wage earning capacity. INTERROGATORY NO. 11: Please state the identity and location of all persons having knowledge of any discoverable matter. Please state the identity and location of all persons who may be called as witnesses at the trial and please state the oral testimony of said witnesses. INTERROGATORY NO. 12: State the name of each person, including experts, having knowledge of relevant facts related to the incident, which is the basis of this suit, the cause thereof, or the damages resulting therefrom. INTERROGATORY NO. 13: When did the Claimant's employer or supervisory personnel first have knowledge that the Claimant sustained or claimed to have sustained an accidental injury. INTERROGATORY NO. 14: State whether or not Claimant reported to the employer that he had sustained an injury and, if so, state the name and address of each person to whom Claimant reported. INTERROGATORY NO. 15: State the name and address of the foreman or supervisory employee in charge of the work being done by the Claimant at the time of the occurrence in question. INTERROGATORY NO. 16: Which of the doctors inquired about in the preceding Interrogatories examined or treated the Claimant on behalf of or at the request of the Defendant's Insurance Company? INTERROGATORY NO. 17: What bills or charges for medical, hospital, or pharmaceutical treatment of the Claimant has Defendant been presented with which Defendant has refused to pay? INTERROGATORY NO. 18: During the twelve month period immediately preceding the alleged date of injury, what benefits of employment were afforded to the employee, including but not limited to, board, lodging, laundry, uniforms, per diem, discounts on merchandise, profit sharing, fuel, meals, insurance benefits, retirement benefits, or other thing of privilege or value? INTERROGATORY NO. 19: What is the monetary value of each item listed in the preceding Interrogatory No. 18? INTERROGATORY NO. 20: What does the Employer contend to be the correct average daily wage applicable in this case. INTERROGATORY NO. 21: State whether or not Claimant's work before the alleged date of injury was considered satisfactory to the employer and supervisory personnel. If not, state each reason why Claimant's work was not considered satisfactory. INTERROGATORY NO. 22: State whether or not Claimant's work, if any, after the above date was considered satisfactory by Claimant's employer and supervisory personnel. If not, state each reason why Claimant's work was not considered satisfactory. INTERROGATORY NO. 23: Does the Defendant contend that any pre-existing disease, injury or bodily conditions, does or will contribute in any degree to the Claimant's incapacity made the basis of this suit? If so, describe in detail. INTERROGATORY NO. 24: Does the Defendant contend that any disease, injury, or bodily conditions, occurring after alleged date of injury, has, does or will contribute in any degree to the Claimant's incapacity made the basis of this suit? If so, describe in detail. INTERROGATORY NO. 25: State whether or not Claimant's employer has received from or on behalf of Claimant any request or claim for any type of lost time, medical, hospital or sickness benefits following the alleged date of injury (exclusive of worker's compensation). INTERROGATORY NO. 26: Please state whether or not you have a copy of any statement, which the Claimant has previously made concerning this action or its subject matter and which is in your possession or control. If so, please state the contents of this statement and how it was recorded and by whom it was recorded. INTERROGATORY NO. 27: Please state whether you have any photographs or movies or similar recordings of the Claimant. Respectfully submitted, this the _________day of ______________, _____. ___________________________________ ____________________ Attorney for Claimant CERTIFICATE OF SERVICE I, _____________, do hereby certify that I have this day mailed, United States mail, Postage prepaid, a true and correct copy of the above and foregoing Interrogatories to the__________, at his usual business address of __________. SO CERTIFIED this the _________ day of________________, ____. ______________________________ ____________________