Fill and Sign the Workers Compensation Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) PLAINTIFF'S REQUEST FOR PRODUCTION OF DOCUMENTS TO DEFENDANT, ___________________ COMPANY Plaintiff requests that the Defendant, ___________________ COMPANY, produce for inspection and copying, prior to the expiration of _____ days from the date of service hereof, the following: 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; - 2 - memoranda; diaries (whether written, electronic or computerized); summaries; notes or other typed or written recordings of telephone conversations; notes of personal conversations, 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; invoic es; 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 ___________________ COMPANY, their agents, servants and/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; - 3 - (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: (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. Produce a true and correct copy of Plaintiff's personnel file maintained by the Defendant. 2. Produce a true and correct copy of any and all medical records maintained by the Defendant or any and all of its representative regarding the Plaintiff. 3. Produce a true and correct copy of the first report of injury regarding Plaintiff's injury made the basis of this complaint. - 4 - 4. Produce a true and correct copy of any and all statements obtained from the Plaintiff at any time during the course of his employment. 5. Produce a true and correct copy of the resume and/or curriculum vitae of all expert witnesses you anticipate calling to testify at the trial of this cause. 6. Plaintiff requests that the Defendant produce each of the following documents:(a) Employee handbook; (b) Company Personnel Manual; (c) Newspaper want-ads seeking new employees; (d) Job applications of workers hired to replace the Plaintiff; (e) Medical file on the Plaintiff; (f) Any inter-office memos pertaining to the Plaintiff's Worker's Compensation claim, termination or otherwise; (g) The Worker's Compensation file kept by the Defendant on the Plaintiff; (h) Documentation concerning plaintiff’s wages, insurance benefits (including life, health, and disability benefits); (i) Documentation concerning plaintiff’s pension, 401(k) and/or other retirement benefits); (j) Documentation concerning other benefits provided or otherwise available to plaintiff; (k) Premium notices from the worker’s compensation carrier; (l) Personnel file for the plaintiff. - 5 - 7. Produce each and every document that you contend supports your position that Plaintiff was terminated due to anything other than her filing a Worker’s Compensation claim. 8. Produce each and every document, which reference in anyway Plaintiff's termination. 9. Produce all documents identified by you in response to interrogatory ______. 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____. _________________________________ PLEASE SERVE WITH COMPLAINT ON DEFENDANT, _______________ COMPANY.