New Jersey Uniform Interrogatories - Form A

All questions must be answered unless the court otherwise orders or unless a claim of privilege or protective order is made in accordance with R. 4:17-1(b)(3).

Form A.

Uniform Interrogatories to Be Answered by Plaintiff

in All Personal Injury Cases (Except Medical Malpractice Cases)

New Jersey Superior Court

1. Full name, present address, date of birth, Social Security number, and Medicare number, if applicable. If Medicare number is applicable, attach a copy of the Medicare card.

2. Describe in detail your version of the accident or occurrence setting forth the date, location, time and weather.

3. Detailed description of nature, extent, and duration of any and all injuries.

4. Detailed description of injury or condition claimed to be permanent together with all present complaints.

5. If confined to a hospital, state its name and address and dates of admission and discharge.

6. If any diagnostic tests were performed, state the type of test performed, name and address of place where performed, date each test was performed and what each test disclosed. Attach a copy of the test results.

7. If treated by any health care provider, state the name and present address of each health care provider, the dates and places where treatments were received and the date of last treatment. Attach true copies of all written reports provided to you by any such health care provider whom you propose to have testify in your behalf.

8. If still being treated, the name and address of each doctor or health care provider rendering treatment, where and how often treatment is received and the nature of the treatment.

9. If a previous injury, disease, illness or condition is claimed to have been aggravated, accelerated, or exacerbated, specify in detail the nature of each and the name and present address of each health care provider, if any, who ever provided treatment for the condition.

10. If employed at the time of the accident, state: (a) name and address of employer; (b) position held and nature of work performed; (c) average weekly wages for past year; (d) period of time lost from employment, giving dates; and (e) amount of wages lost, if any.

11. If there has been a return to employment or occupation, state: (a) name and address of present employer; (b) position held and nature of work performed; and (c) present weekly wages, earning, income, or profit.

12. If other loss of income, profit or earnings is claimed: (a) state total amount of the loss; (b) give a complete...