Uniform Personal Injury Interrogatories

Clients of our office may be requested to complete the Uniform Personal Injury Interrogatories during the handling of their cases. Interrogatories are written questions that must be answered under oath which are then submitted to the defendant’s attorney, and which may be used against you in court. Our office will review all submissions and contact you prior to finalizing your answers to these questions, to make sure you have properly completed them and to obtain your signature on the completed document. If you have questions about any item, you should fill the questionnaire out as best you can and contact us to schedule an appointment to review your answers.

1.State your name and address or principal place of business, date of birth and social security number.

2.Have you ever been a party to a civil lawsuit? Yes No If so state:
      a. Were you plaintiff or defendant?

      b.What was the nature of the plaintiff's claim?

      c. When, where and in what court was the action commenced?

      d. State the names of all the parties other than yourself.

3.State exactly and in detail your version of how this accident occurred.

4.Who's fault do you think the accident was and why?

5.Was an investigation conducted concerning the accident in question? Yes No If so state:
      a. The name, address and occupation of the person or organization conducting the investigation.

      b. The date or dates on which the investigation was conducted.

      c. Whether you or anyone acting on your behalf has interviewed or spoken with defendant or any of its agents or employees about the event in question. Yes No If so, please identify the individual spoken with and the substance of the conversation.

      d.The name and address of the person now having custody of any written report made concerning the investigation.

6.Describe in detail all injuries, whether physical, mental or emotional, experienced since the occurrence and claimed to have been caused, aggravated or otherwise contributed to by it.

7.As to each medical practitioner who has examined or treated any of the persons named in your answer to Interrogatory No. 1 above, for any of the injuries or symptoms described, state:
      a. The name, address and specialty of each medical practitioner.

      b. The date of each examination or treatment.

      c. The physical, mental or emotional condition for which each examination or treatment was performed.

8. State as to each item of medical expense attributable to the accident:
      a. The name and address of the person or organization paid or owed therefore.

      b. The amount.

      c. The date of each item of expense (attach copies of the itemized bills, if desired).

      d.The person or organization who paid the medical expense.

      e. The condition for which you incurred the expenses.

      f. Will you incur medical expenses in the future as a result of the accident in question?* If so, state the amount of medical expenses which will be incurred in the future and state in detail the knowledge and source upon which you rely in support of this belief.

9.Do you claim to have lost any time from gainful employment as a result of the accident? Yes No If so, state:
      a. The specific condition which you claim caused the loss of time.

      b. The amount of time lost.

      c. The rate of pay or compensation regularly received from each such gainful employment.

      d.If you claim any damage as a result of the time lost, the total and your method of computation.

10.If your answer to Interrogatory No. 13 is yes, list each job or position of employment including self-employment, held by you on the date of and since the accident, stating as to each, the following:
      a. Name and address of employment.

      b. Date of commencement of and date of termination.

      c. Place of employment.

      d.Nature of employment and duties performed.

      e. Name and address of immediate supervisor.

      f. Rate of pay or compensation received.

11.Do you claim that your ability to engage any type of gainful employment has been affected by the accident? Yes No If so, state:
      a. The specific condition which limits your ability to engage in gainful employment.

      b. The economic loss caused by your inability to find gainful employment.

      c. Your method of computation for computing such loss.

12. Do you have liability insurance or are you aware of any other form of indemnity which you claim is applicable to this accident?
Yes No If the answer is yes, state:
      a. The name of the company or companies, including any excess or umbrella carriers, which you claim provide coverage.

      b. The policy number or numbers of any applicable policy.

      c. The limit or limits of liability of each policy.

      d.The named insured on each policy.

      e. Whether the insurance carrier has accepted or denied coverage.

      f. Whether you are being defended by the insurance carrier under a reservation of rights.

13. State the name, address and occupation of the owner of the vehicle alleged in the plaintiff's complaint to have caused damage to the plaintiff.