Interrogatories - Tort Related Actions

Basic Damages

[A] Physical Injuries

1. Do you claim that you suffered any physical injuries, pain or disability as a result of the subject accident? If so, with respect to all of the injuries, pain and disability, if any, that you claim resulted from the subject accident, please provide the following information:

   1. The nature of the physical injuries, pain or disability and date and approximate time at which you first experienced each.

   2. Set forth the name and address of every hospital, doctor, medical and dental professional, rehabilitation house or health care facility from which you sought or obtained assistance; also set forth the date upon which you initially sought such assistance together with the name, title and telephone number of the records custodian for each such facility.

   3. Identify by name, address and occupation each person who has knowledge or information about your physical injuries, pain or disability.

   4. Did you ever experience any of the above mentioned physical injuries, pain or disability prior to the date of the accident? If so, to the extent that you have not already done so, please describe specifically the nature and intensity of the physical injuries, pain or disability as they existed prior to the accident; also, set forth the name and address of every hospital, doctor, medical and dental professional, rehabilitation house or health care facility from which you sought or obtained assistance prior to the date of the accident together with the name, title and telephone number of the records custodian for each such facility.

   5. As a result of your claimed injuries or disabilities, did you apply for, or obtain, any Workers Compensation, Social Security, Medicare, Medicaid, Employment Related benefits, or other Insurance related benefits? If your answer is anything other than an unqualified “No,” then please set forth the following information specifically and in detail for each benefit: The type of benefit applied for, the date that you first applied and a detailed accounting of all sums that you received.

   6. Set forth the amount of compensation that you claim you are entitled to as a result of your physical injuries, pain or disability, and set forth the specific method by which you calculated each amount.

   [B] Emotional Injuries

1. Do you claim that you suffered any emotional distress, mental anguish or psychological injury as a result of the subject accident? If so, please provide the following information:

   1. The nature of the emotional distress or psychological injury, and date and time when it was first experienced.

   2. Set forth the name and address of every psychiatrist counselor, therapist, psychologist or social worker from whom you sought or obtained assistance. Also set forth the date upon which you initially sought such assistance along with the name, title and telephone number of the records custodian for each person.

   3. Identify by name, address and occupation each person who has knowledge or information about your emotional distress.

   4. Did you ever experience any of the above mentioned emotional distress or psychological injury prior to the date of the accident? If so, to the extent that you have not already done so, please describe specifically the nature and intensity of the emotional distress or psychological injury, as it existed prior to the accident. Also, set forth the name and address of every psychiatrist, psychologist, therapist, or social worker from whom you sought or obtained assistance prior to the date of the accident and set forth the name, title and telephone number of the records custodian for each such person.

   5. Set forth the amount of compensation that you claim you are entitled to as a result of your emotional distress or psychological injuries, and set forth the specific method by which you calculated that amount.

      [C] Loss of Earnings

      1. Long Form:

1. Have you lost any time from your employment or from engaging in gainful earnings as a result of the actions, which are the subject of this litigation? If your answer is anything other than an unqualified “No,” then please set forth the following information specifically and in detail for each loss:

   1. The name, address and business of your employer.

   2. Your job title and a detailed description of your job duties.

   3. The period or periods of time during which you missed work as a result of the matters complained of in your complaint. Also, state the actual number of work days that you missed.

   4. The gross and net amounts of any income that you claim was lost.

   5. Your attendance record for the employment in question form the period extending from ________ through ________ .

2. State whether or not you have any documents to substantiate your claimed loss of earnings. If so, then for each such document, please set forth th following information specifically and in detail:

   1. Its title, date, author, purpose, and a summary of its contents.

   2. The name, address and telephone number of the person who has custody of the document.

   3. State whether or not you will, without a motion to produce, attach a copy to your answers to these interrogatories.

3. With respect to each employer that you had at the time of the accident [or incident], which is the subject of your complaint, please provide the following information:

   1. The name, address and business of your employer.

   2. Your job title and a detailed description of your job duties.

   3. Your gross and net earnings for the period of dated ________, 20 __ through ____, 20 __ .

4. Have you been employed or performed any work whatsoever since the date of accident [or incident], which is the subject of your complaint? If your answer is anything other than an unqualified “No,” then please set forth the following information specifically and in detail for each employer:

   1. The name, address and business of your employer.

   2. Your job title and a detailed description of your job duties.

   3. The date upon which you commenced work or employment and the date upon which the work or employment was terminated, if it was terminated.

   4. The gross and net amounts of any income, salary, wages, commissions or sums that you earned.

5. With respect to the preceding _________ [Insert number] years, did you file any federal, state or local income tax returns? If your answer is anything other than an unqualified “No,” then please set forth the following information for each return:

   1. The Form number [i.e., 1040, 1040A, etc.] and the governmental entity with which the return was filed.

   2. The date that the return was filed.

   3. The amount reported as earned income.

   4. State whether or not you will, without a motion to produce, attach a copy to your answers to these interrogatories.

6. For all amounts that you are claiming as lost earnings or income, please provide detailed calculations showing the manner and methods by which you arrived at your total claim.

   2. Short Form:

1. Do you claim that you suffered a loss of earnings as a result of the subject accident? If so, please set forth the following information specifically and in detail:

   1. The amount of the lost earnings and the method by which you calculated the lost earnings.

   2. The name and address of each employer from whom you would have been paid a wage or salary had it not been for the subject accident.

   3. Your monthly wages [or salary] for the period commencing on __________, 20__ and ending on _______, 20 __ .

   4. For each independent job from which you claim that you would have earned money had it not been for the subject accident, please provide details involving any contracts, agreements or past business relationships.

2. For all amounts that you are claiming as lost earnings or income, please provide detailed calculations showing the manner and methods by which you arrived at your total claim.

   [D] Hedonic Injuries

1. Do you claim that you were required to discontinue any sport, recreation, hobby, or activity as a result of the subject accident? If so, please provide the following information for each such sport, recreation, hobby, or activity:¹

   1. The nature of the sport, recreation, hobby, or activity and date upon which you first engaged in it.

   2. The average amount of time (on a daily basis) that you engaged in the sport, recreation, hobby, or activity during the time period commencing on the date set forth in subparagraph “A” above and ending on the date of the accident.

   3. The average amount of time (on a daily basis) that you presently engage in the sport, recreation, hobby, or activity. If you have discontinued the activity, state whether or not you anticipate getting re-involved, and if so, when.

   4. Identify by name, address and occupation each person who has knowledge or information about your participation in the sport, recreation, hobby, or activity.

   5. Indicate the level of proficiency that you achieved (i.e., amateur, professional, etc.).

   6. Set forth the amount of compensation to which you claim that you are entitled as a result of your diminished ability or inability to engage in your recreation, hobby, or activity and set forth the specific method by which you calculated that amount.

2. Are you claiming that the accident diminished your enjoyment of life? If so, please provide the following information:²

   1. Identify by name, address and occupation each person who has knowledge or information about your diminished enjoyment of life.

   2. Set forth the amount of compensation to which you claim you are entitled as a result of your diminished enjoyment of life and set forth the specific method by which you calculated that amount.

   3. Is there anything whatsoever positive that resulted from the accident, such as a greater appreciation of certain aspects of your life or a re-uniting of family members? If your answer is anything other than an unqualified “No,” please provide details with respect to all “positive” changes, attitudes, awareness or feelings.³

   Failure to Mitigate

   [Defendant to Plaintiff]

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