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Rule 4005(c)*(1)(ii). Standard Interrogatories.
_______ by______, attorneys, propound(s) these Interrogatories pursuant
to Pennsylvania Rules of Civil Procedure 4001 et seq. These Interrogatories
are addressed to you as a party to this action and your Answers shall
be based upon information known to you or in the possession of you,
your attorney or other representative acting on your behalf whether
in preparation for litigation or otherwise.
Each of these Interrogatories must be answered fully and completely
by you in writing and must be signed by you under oath before a Notary
Public, or otherwise properly verified.
Pennsylvania Rule of Civil Procedure 4006 requires filing and service
of your Answers on Defendant's counsel within thirty (30) days after
service of these Interrogatories.
Supplements to your Answers shall be filed in accordance with Pennsylvania
Rule of Civil Procedure 4007.4.
Unless otherwise indicated, the word "accident" refers
to the occurrence stated in plaintiff's complaint.
You will note that an original and two copies of the Interrogatories
have been served upon you. Space has been provided below each Interrogatory
for your answers. If additional space is required for answers, either
use the reverse side of said paper or attach an additional sheet
of paper appropriately marking said Interrogatory.
BY: ____________________________________________
Attorneys for
PERSONAL DATA:
l. State:
(a) Your full name.
(b) Each other name, if any, which you have used or by which you have been
known;
(c)The name of your spouse at the time of the accident; date and place of your
marriage to such spouse.
(d) Your present residence address and the address of each other residence
which you have had during the past five years.
(e) Present occupation and the name and address of your employer.
(f) Date of your birth and present age.
(g) Your Social Security number.
MEDICAL INFORMATION
2. State in detail all injuries sustained by you in the accident
upon which this suit is based.
3. Were you examined or treated by any person or institution as
a result of the accident? ____ If so, state as to each:
(a) The name and address of any hospital where you received an examination
or treatment, the dates, the nature of the treatment rendered, and
the amount charged.
(b) Name and address of any person or institution which x-rayed any part of
your body, the dates and the amounts charged;
(c) the name, address and professional specialty of any person who examined
or treated you, the dates, the amounts charged, the persons findings.
4. As a result of the injuries you have described above, were you
confined to bed or your home? ____ If so, state the dates you were
confined to each.
5. Have you received any medical reports from any person or institution
where you were x-rayed, examined or treated? ____ If so, attach copies
of the reports to your Answers. If you have not received any medical
reports from any person or institution where you were examined or
treated for injuries sustained in the accident or any preexisting
condition, you are requested to sign the attached "Medical Consent" form
so we can obtain these reports and records. We will make available
to you all reports and records obtained by use of the Consent.
6. Did you employ any nursing service since the accident'? ____
If so, state the name, address, period of employment, rate of pay
and total amount paid for nursing services.
7. Do you claim absence from school at any time since the accident? ____ If
so, state as to each absence:
(a) Exact dates of absence and the reasons for the absence;
(b) Name and address of the school you were attending at the time of the accident,
what grade you were then in and name and address of schools attended up to
the date of answering these Interrogatories;
(c) Whether you claim any impairment of your educational program, and, if so,
how the program was impaired;
(d) If you are claiming the absence from school or impairment of educational
program, you are requested to sign the attached "Scholastic Consent" so that
we can obtain copies of your scholastic records. We will make available to
you all scholastic records obtained by the use of the Consent.
PRESENT CONDITION
8. As to each injury from which you have fully recovered, state
the approximate date of such recovery.
9. Describe with particularity any pain, ailment, complaint, injury,
scarring or disability you presently have as a result of the accident.
10. Are you still under treatment for injuries you allege you sustained
in the accident ? ____ If so, state the full name of the person(s)
treating you and the date(s) of the last visit.
11. Are you able to perform your normal daily activities?____ If not, specify
in what way you are not able to perform those activities.
PREVIOUS OR SUBSEQUENT ACCIDENTS
12. Have you ever been involved in an accident of any kind before
or after this accident'? ____ If so, state:
(a) Date and place of the accident;
(b) Names of the parties to the accident;
(c) Nature of the injuries you sustained.
13. Have you ever filed a lawsuit for personal injuries? ____ If so, state
to Court, term and number of the suit and the date the suit was filed.
PRE-EXISTING CONDITIONS
14. Have you sustained any injuries or had any disease or impairment,
physical or mental, before the accident which in any way affected
those parts of your body injured in this accident? ____ If so, state:
(a) Nature of such injury, disease or impairment;
(b)Name and address of any hospital, institution, doctor or other person who
examined you;
(c) Dates of the treatment or examination.
15. Did this accident aggravate a pre-existing medical condition? ____ If so,
state the nature of the pre-existing condition and how it was aggravated.
EMPLOYMENT
16. Do you claim absence or loss of earning from employment because
of the accident? ____ If so, state for each employer:
(a) Name and address at the time of the accident;
(b) Nature of employment and usual duties:
(c) Dates of absence from employment;
(d) Date first returned to work following the accident;
(e) Rate of pay;
(f) Total amount of loss and how the sum was computed;
(g) Name and address of any person having knowledge of the above;
(h) Have you obtained any reports or records from your employer in regard to
the loss of wages and loss of earning capacity? ____ If so, attach a copy of
said records to your Answers. If you have not obtained any records, you are
requested to sign the attached "Employment Records Consent" to enable us to
obtain copies of your employment records. We will make available to you all
records obtained by use of the Consent.
17. Do you claim any loss of earning capacity or impairment of your
ability to work as a result of the accident. ____ If so, specify
the nature of your claim.
18. Do you claim any loss of earnings or profits from self-employment
as a result of the accident'? ____ If so, state:
(a) Address of your usual place of employment;
(b) Name under which you did business;
(c) Nature of your self-employment;
(d) Exact dates you were unable to engage in your self-employment by reason
of the injuries sustained in the accident;
(e) Date you first resumed regular activity after the accident;
(f) Names and addresses of any employees hired as a result of your disability
and the dates of their employment;
(g) Amount you claim as lost earnings or profits and exactly how the sum is
calculated;
(h) Attach copies of all financial statements and business records upon which
you claim any lost earnings or profits.
FEDERAL TAX RETURNS
Interrogatories 19, 20 and 21 are proposed only if loss of earnings
or earning capacity is claimed.
19. State your gross and net income as stated in, our Federal Income
Tax Returns for each of the three years immediately preceding the
date of the accident and for each of the years thereafter to date.
20. Have you retained copies of your Federal Income Tax Returns
for three years before the date of the accident and for each of the
years thereafter to date? ____ If so, attach copies of, our Federal
Income Tax Returns for those years.
21. If you have not retained copies of your Federal Income Tax Returns,
you are requested to sign the attached" Request for Copy of Tax Form" to
enable us to obtain copies of said records. We will make available
to you all tax returns obtained by use of the Request.
OTHER FINANCIAL LOSS
22. Do you claim any other financial losses not listed above as
a result of the accident'? ____ If so, list those items with detail
as to kind, date and amount.
23. If married, does your spouse claim any financial or other loss
as a result of the accident? ____ If so, detail the kind of loss,
the dates and, if applicable, to whom money was paid.
BASIC LOSS BENEFITS
24. What is the name, address, claim number and claim representative's
name of the insurance company which insured you and/or your vehicle
for Basic Loss (PIP) Benefits at the time of the accident?
WITNESSES
25. Do you know of any person(s) you believe to be an eyewitness
to the accident or the events leading up to the accident'? ____ If
so, as to each person, state:
(a) Name and present or last known address:
(b) Name and address of his/her present or last known employer:
(c) Exact location of person at time of the accident.
26. Do you know of any person(s) you believe has any knowledge of
the conditions at the scene of the accident existing before, during
or immediately after the accident other than eyewitnesses? ____ If
so, as to each person, state:
(a) Name and present or last known address;
(b) Name and address of his/her present or last known employer;
(c) Exact location of person at time of the accident.
27. If not previously stated above, do you know of any person(s)
you believe has knowledge of events leading up to the accident, facts
pertaining to this suit, or facts of any investigation after the
accident'? ____ If so, as to each person, state:
(a) Name and present or last known address;
(b) Name and address of his/her present or last known employer.
28. At the time of the accident or immediately thereafter, did you
have any conversation with any person at or near the scene of the
accident or did any person converse with you or in your presence
relevant to the accident or injuries sustained? ____ If so, state:
(a) Name and address of each person who spoke:
(b) Words or substance of each conversation;
(c) Name and address of any person within hearing distance of the conversation.
29. State the names and addresses of all persons who it is your
intention to call as witnesses at the trial of this case. (Other
than expert witnesses.)
INVESTIGATION
30. Have you or anyone acting on your behalf obtained from any person
any report, statement, recording, memorandum or testimony, whether
signed or not, and whether prepared by someone else, concerning this
accident? ____ If so, attach copies to your Answers and state as
to each person:
(a) Name and address of the witness or person from whom the item was obtained;
(b) Date the item was taken or made;
(c) Name and address of the person obtaining the item.
31. Have you ever made any report, statement, memorandum, recording
or given testimony in writing, whether prepared by you or someone
else, concerning this accident or the suit? ____ If so, attach copies
at cost of interrogating party to your Answers and state:
(a) Nature and date the item was prepared;
(b)Where the item is now located if not available to you.
32. Do you know of any photos or motion pictures, plans, drawings,
blueprints, sketches or diagrams made by anyone other than counsel
regarding this occurrence or the location of the occurrence?____
If so, attach copies at cost of interrogating party to your Answer
and state as to each item:
(a) Exact nature of the item;
(b) Date the item was made or taken:
(c) Where the item is now located if not available to you.
ACCIDENT
33. State the exact date, time and place of the accident and describe
in detail how you claim the accident occurred.
34. State in detail those facts upon which you base your claim that
this defendant, or any of the other defendants, were negligent as
averred in your Complaint.
35. Do you allege any mechanical defects in a vehicle or traffic
control caused or contributed to the accident? ____ If so, state
the facts upon which you rely.
36. At the time of the accident, or immediately before, did you
have any temporary or permanent impairment or restriction of vision,
hearing, muscle control or other bodily functions? ____ If so, state
the details thereof.
37. At the time of the accident, or within twenty-four (24) hours
prior thereto, did you ingest any medication or alcoholic beverages?
____ If so, state the details thereof.
38. What are the restrictions on your operator's license?
THE REMAINING INTERROGATORIES MAY BE ASKED IF APPLICABLE
PROPERTY DAMAGE
39. Did the vehicle you owned or operated at the time of the accident
sustain any damage? ____ If so, state:
(a) Name and address of the registered owner;
(b) Year, manufacturer, model and serial number of the vehicle;
(c) Your relationship to the owner of the vehicle;
(d) Parts of the vehicle you allege were damaged in the accident.
40. Has the vehicle been repaired since the accident? ____ If so,
state:
(a) Name and address of the repairer;
(b) Cost of repairs and by whom paid.
41. If the vehicle has not been repaired, state:
(a) Name and address of the person(s) who prepared an estimate;
(b) Amount of the estimate(s);
(c) Attach a copy of the estimate to your Answers.
42. Was the vehicle covered by collision insurance? ____ If so,
state:
(a) Name, address and claim number of the insurance company;
(b) Amount paid and the amount of any deductible.
43. Are you making any other claim for damage to property or automobile
rental? ____ If so, specify the nature and amount of the claim.
EXPERT WIT'NESSES
44. If you intend to call an expert witness at trial, state:
(a) The name and address of each such expert witness;
(b) The subject matter as to which each such expert witness is expected to
testify;
(c) The substance of the facts and opinions to which each expert is expected
to
testify and a summary of the grounds for each opinion and/or attach a copy
of each expert's report to your Answers to Interrogatories;
(d) The educational background, field of expertise, professional experience
of each of the expert witnesses identified in your Answers above.
TESTS
45. If any tests or procedures have or will be performed by any
expert retained by you, your attorney, consultant, surety, indemnitor,
insurer or agent in this action, whether or not you intend to call
that expert witness at trial, state:
(a) The name and address of the person conducting the test, including
the name of each person's employer;
(b) The educational background, field of expertise, professional experience,
publications, membership in professional societies, employment experience and
court appearances (including citations) of each of the expert witnesses identified
in your Answers above;
(c) The location where each test or procedure was or is scheduled to be conducted;
(d) The date when each test or procedure was or is scheduled to be conducted:
(e) The result of each test or procedure completed to date:
(f) The name and address of the person currently in custody of the object tested.
(g) Attach a copy of the report of each expert identified in your Answers above.
PRODUCT DEFECT
46. Do you, your representative, attorney, consultant, surety, indemnitor,
insurer or agent have or known of any facts upon which you alleged
or contend that a product of the interrogating defendant, which is
alleged to be involved in this action, was defective? ____ If so,
state:
(a) Specifically identify the product by name, number, model, etc.;
(b) State in detail and specifically the defective condition that allegedly
existed;
(c) Each and every fact upon which you contend or allege said product was defective;
(d) The name, address and job classification of all the persons known to you
or to those identified in the preamble of this interrogatory who have knowledge
of such facts and state what facts as to the alleged defectiveness of said
product is within the knowledge or possession of each of such persons;
(e) Identify each and every writing by date and author of which you know, if
there are any, which support your allegation or contention that said product
was defective.
WARRANTY
47. Do you, your representative, attorney, consultant, surety, indemnitor,
insurer or agent have or know of any facts upon which you allege
or contend that the interrogating defendant breached any warranty
whatsoever to you or anyone else in regard to the specific product
of the interrogating defendant which is allegedly involved in this
action? ____ If so, please state:
(a) Each and every fact upon which you contend or allege that the
interrogating defendant breached any warranties whatsoever to you
or anyone else in regard to the specific product which is allegedly
involved in this action;
(b) The name, address and job classification of all persons known to you or
to those identified in the preamble of this interrogatory who have knowledge
of such facts and state what facts as to the alleged breach of warranty is
within the knowledge or possession of each of said persons;
(c) Identify each and every writing by date and author of which you know if
there are any which support your allegation or contention that interrogating
defendant breached any warranty.
BY: ____________________________
Attorneys for