Fill and Sign the Interrogatories to Defendant Workers Compensation Wrongful Termination Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) PLAINTIFF'S INTERROGATORIES TO DEFENDANT ___________________ COMPANY Plaintiff requests that the Defendant, ___________________, fully answer the following discovery requests pursuant to the _____________ Rules of Civil Procedure: DEFINITIONS 1. The term "documents" means: all writings of any kind, including the originals and all non-identical copies, whether different from the originals by reason of any notation made on such copies or otherwise, and whether printed, recorded, created or reproduced by any mechanical means or process, or written or produced by hand, including, but not limited t o: agreements; contracts; drafts of agreements or contracts; written material re ferencing oral agreement or contracts; confirmatory memoranda; letters of intent; orders; purchase orders; communications; messages; correspondence; personal calendars (whether written electronica lly or computerized); letters; postcards; telegrams; teletypes; telefax; mailgram s; tape recordings; memoranda; diaries (whether written, electronic or computerized); summaries; notes or ot her typed or written recordings of telephone conversations; notes of personal conversations, - 2 - meetings or statements; records; files; intra-office and interoffice memoranda and communications; personal memoranda; photographic slides; pictures; motion picture films; microfilm; microfiche; newspapers; magazine; charts; graphs; drawings; bookkeeping entries; account summaries or statements; financial statements; balance sheets; invoices; bills; orders; receipts; bank records of all types; notes of interviews; statements of witnesses; findi ngs of investigations; reports of experts who are expected to be called to trial; ma terials furnished to experts expected to be called to trial; cassettes; micro-cassettes; comput er discs; pamphlets; bulletins; posters; blueprints; drawings; plans; sketches; safety reports; job analysis; invest igation reports; safety audits; safety recommendations; safety books; safety manuals; written or pri nted warnings; test results; opinions or conclusions from test results or investigations; and letters, logs, both rough and smooth. 2. "Defendant" means ___________________, their agents, servants or employees. 3. "Identify" when referring to a document requests that the following information be supplied: (a) A description of the document; (b) The date of the document; (c) The name or names of any individual who may have authored the document or provided information for the document; (d) The name or names of any individual to whom the document was sent; (e) A general description of the subject matter of the document; (f) The name or names of any person who sent the document. 4. "Identify" when using reference to a person or company or entity requests that the following information be supplied: - 3 - (a) The correct name of that person or entity; (b) The correct name of that person's employer and job title if reference is made to a person. INSTRUCTIONS 1. Whenever information is requested, the request should be deemed to include information available to this Defendant, its past and present insurance carrier or carri ers, its attorneys and all officers, agents and/or employees of this Defendant. 2. Should this Defendant deem to be privileged to any documents whose information or inspection is requested by any of the following discovery requests, this Defendant shall list such documentation in the manner above indicated, and in addition to supplying the above -noted information concerning such documents, this Defendant shall indicate what privilege is cl aimed and shall briefly state the ground on which the claim of privilege rests, in order that the Plaintiff may have the factual basis to determine whether or not such documents are, in fact, privileged. ************************** 1. Identify each and every employee, by name, last known phone number, and last known address, at _______________________ who has been terminated within the past five (5) years. 2. For each employee listed in your response to question 1 above:(a) State the date the employee was terminated or ceased working for Defendant. (b) State each and every reason why said employee was terminated. - 4 - 3. Identify each and every employee by name, last known phone number, and last known address, at _________________________ that has sustained an on the job injury within the five (5) years prior to the date of the filing of this claim. 4. For each employee listed in your response to question 3 above:(a) State the date of said employee's injury. (b) The type of injury suffered by the employee. (c) State whether said employee is still an employee of ___________________, Inc. (d) If the individual is not an employee, state the date said individual was terminated as well as ALL reasons for said termination. 5. State ALL reasons plaintiff was terminated from ________________, and (a) Each and every individual who participated in the decision to terminate Plaintiff; (b) Whether the Plaintiff was consulted prior to her termination; (c) The name of the individual that informed the Plaintiff of her termination. (d) Describe in detail the circumstances surrounding the Plaintiff being informed of her termination. 6. Has the Defendant been sued in any state or federal court in ____________ for retaliatory discharge in violation of §_________ of the Code of ____________? If so, give the name of the employee filing suit, the name and address of the employee's attorney, t he - 5 - jurisdiction in which the suit was filed and the case number, and the result of the litigation if it is not still pending. 7. Describe in detail each and every fact upon which you rely upon in stating that t he Plaintiff's employment was terminated other than for filing a workers’ compensation claim. 8. State the name, last known phone number and last known address of every employee hired at _________________________ from the ____ day of ____________, 20____, through the present. 9. Please describe the nature of Plaintiff's job at the time and date she was injured. 10. Has Plaintiff's job been filled since the date of her injury; if so, state:(a) The name and address of the employee hired to fill Plaintiff's job; (b) The date the employee was hired to fill Plaintiff's job. 11. Please state the name, address and contact person of any and all employment agencies utilized by ___________________, Inc. to hire employees at anytime during the years ________ to the present. 12. Describe each and every problem with plaintiff’s job performance before her on- the-job injury. (a) Describe all discipline, if any, which was used for each performance problem. 13. Describe each and every problem with plaintiff’s job performance after her on- the-job injury. (a) Describe all discipline, if any, which was used for each performance problem. - 6 - 14. If you claim plaintiff acted or omitted to act in a manner which contributed to her termination from her job, (a) State what plaintiff did that you claim that she should not have done; (b) State what plaintiff did not do which you claim that she should have done. 15. With respect to each statement, remark, comment or communication made by anyone, including, but not limited to, any statement or admission you contend is against plaintiff’s interests concerning the incident made the basis of this suit, please state: (a) The name, last known address, and last known telephone number of EACH person making the statement, etc.; (b) The substance of EACH statement, etc., made; (c) The name, last known address and last known telephone number of EACH person to whom the statement, etc., was made and/or who heard the same and/or who was present when the statement, etc. was made, including in your answers any responses thereto; 16. The name, last known address and last known telephone number of EACH person who: (a) Was a witness of the incident made the basis of this suit; (b) You, your attorney, you insurance company, or anyone acting on your behalf has talked to concerning any matter involving the incident made the basis of this suit; (c) Has discoverable information concerning the incident made the basis of this suit; - 7 - (d) From whom, your attorney, your insurance company, or anyone acting on your behalf has taken a statement from, in any form whatsoever. 17. If you contend you are not liable to the plaintiff for the incident made the basis of this suit, for any reason whatsoever , please state: (a) Each and every contention or reason why you contend you are not liable to the plaintiff; (b) Each and every fact and/or the basis for each contention or reason why you contend you are not liable to the plaintiff; (c) State the name, last known address and last known telephone number of EACH and every witness, expert or otherwise, to correspond with each and every contention or reason why you allege you are not liable to the plaintiff for the incident made the basis of this suit; (d) Identify each and every document and/or tangible item specifically identifying the corresponding reason or contention why you are not liable to the plaintiff sufficiently enough to allow the plaintiff to obtain the same by request for production of documents and/or tangible items. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 8 - 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____. _________________________________ PLEASE SERVE WITH COMPLAINT ON DEFENDANT