Fill and Sign the Personal Injury Accident Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) FIRST SET OF REQUESTS FOR ADMISSIONS PROPOUNDED BY PLAINTIFF TO DEFENDANT The Plaintiff, _________________, propounds this his First Set of Requests for Admissions pursuant to Rule __ of the __________ Rules of Civil procedure, requesting that the Defendant admit or deny the truthfulness of said requests within __________ (___) days of service hereof. DEFINITIONS The term "accident" as used herein means the occurrence described in the complaint. REQUESTS FOR ADMISSIONS Request No. 1: That Defendant was the operator of the Chevrolet automobile that collided with the rear of Plaintiff's automobile on the _____ day of _____________, 20___. Request No. 2: That Defendant was the owner of the Chevrolet automobile that collided with the rear of Plaintiff's automobile on the _____ day of _____________, 20___. Request No. 3: That on the _____ day of _____________, 20___ , Defendant drove his automobile into the rear of Plaintiff’s automobile. - 2 - Request No. 4: That Defendant drove his automobile into the rear of Plaintiff's automobile. Request No. 5: That the front of the Defendant’s automobile collided with the rear of the Plaintiff’s automobile. Request No. 6: That Plaintiff's automobile was stopped at the time of the accident. Request No. 7: That Plaintiff's automobile was stopped when Defendant drove his automobile into the rear of Plaintiff’s automobile. Request No. 8: That at the time of the accident failed to have his autom obile under proper control. Request No. 9: That at the time of the accident, Defendant failed to mai ntain a proper lookout. Request No. 10: That at the time of the accident, Defendant failed to mainta in a reasonable distance behind Plaintiff’s automobile so as to avoid colliding with Plai ntiff’s automobile. Request No. 11: That at the time of the accident, Defendant was negligent as a matter of law in violating Section _____ of the ________ Code Annotated. Request No. 12: That Defendant was negligent in colliding with the rear of Plaintiff's vehicle. Request No. 13: That the accident was proximately caused by Defendant's failure to keep his vehicle under control, keep a proper look-out ahead, and to drive at a speed and sufficient distance behind Plaintiff's automobile to avoid colliding with Plaintiff's automobile. Request No. 14: That at the time of the accident made the subject of this sui t, Plaintiff's automobile was stopped at the intersection of Highway ___ and _____ Road. - 3 - Request No. 15: That at the time of the accident the brake lights on Plaintiff's automobile were functioning. Request No. 16: That at the time of the accident Defendant negligently drove his automobile into the rear of Plaintiff’s automobile. Request No. 17: That Defendant proximately caused the accident. Request No. 18: That Defendant proximately contributed to the accident. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: 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____.