§ Form 5 Uniform Personal Injury Interrogatories
Form 5. Uniform Personal Injury Interrogatories
INSTRUCTIONS FOR USE
A. All information is to be divulged which is in the possession of the individual or corporate party, his attorneys, investigator, agents, employees, or other representative of the named party.
B. A “medical practitioner” as used in these interrogatories is meant to include any person who practices any form of healing arts.
C. Where an individual interrogatory calls for an answer which involves more than one party, each part of the answer should be clearly set out so that it is understandable.
D. Where the terms “you”, “your”, “plaintiff”, or “defendant” are used, they are meant to include every individual party, and separate answers should be given for each responding person or party, if requested.
E. Where the terms “accident(s)” or “incident(s)” are used, they are meant to mean the incident which is the basis of this lawsuit, unless otherwise specified.
INTERROGATORIES
Interrogatory No. 1: State your name and address or principal place of business, date of birth, and social security number.
Interrogatory No. 2: Have you been convicted of a felony? ___ If so, for each felony state:
A. The original charge made against you.
B. The charge of which you were convicted.
C. Did you plead guilty of the charge or were you convicted after trial?
D. The court and cause number.
Interrogatory No. 3: Have you ever been a party to a civil lawsuit? ___ If so, state:
A. Were you plaintiff or defendant?
B. What was the nature of the plaintiffs' claim
C. When, where, and in what court was the action commenced?
D. State the names of all the parties other than yourself.
Interrogatory No. 4: State exactly and in detail your version of how this accident occurred.
Interrogatory No. 5: State specifically and in detail the facts upon which your contention is based that the accident was caused by a negligent conduct of another party, including former parties, or non-party.
Interrogatory No. 6: Was an investigation conducted concerning the accident in question? ___ 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 any other party or any of its agents or employees about the event in question. ___ 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.
Interrogatory No. 7: Do you know of any person who is skilled in any particular field or science, including the field of medicine, whom you may call as a witness upon the trial of this action and who has expressed an opinion upon any issue of this action? ___ If so, state:
A. The name and address of each person.
B. The field or science in which each such person is sufficiently skilled to enable opinion evidence in this action.
C. Whether such potential witness will base his or her opinion:
1. In whole or in part upon facts acquired personally by him or her in the course of an investigation or examination of any of the issues of this case, or
2. Solely upon information as to the facts provided him or her by others.
D. If your answer to 7(C) discloses that any such witness has made a personal investigation or examination relating to any of the issues of this case, state the nature and dates of such investigation or examination.
E. Each and every fact, and each and every document, item, photograph, or other tangible object supplied or made available to such person.
F. The general subject upon which each such person may express an opinion.
G. Whether such persons have rendered written reports. ___ If so:
1. Give the dates of such report.
2. State the name and address of the custodian of such reports.
Interrogatory No. 8: 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.
Interrogatory No. 9: For all injuries mentioned in the proceeding interrogatory, please identify those injuries which are considered by you to be permanent.
Interrogatory No. 10: As to each medical practitioner who has examined or treated any of the persons named in your answers 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.
Interrogatory No. 11: 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 for the medical expense.
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 expense.
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.
Interrogatory No. 12: List each injury, symptom, or complaint mentioned in answer to Interrogatory No. 8 from which you suffered at any time before the accident.
Interrogatory No. 13: Do you claim to have lost any time from gainful employment as a result of the accident? ___ 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.
Interrogatory No. 14: 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.
Interrogatory No. 15: Do you claim that your ability to engage in any type of gainful employment has been affected by the accident? ___ 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.
Interrogatory No. 16: Provide the identity and location of any nonparty identified in your response to Interrogatory No. 5 above, who you claim, pursuant to A.R.S. § 12-2506(B) (as amended), was wholly or partially at fault in causing any personal injury, property damage, or wrongful death for which damages are sought in this action.
Interrogatory No. 17: Do you have liability insurance or are you aware of any other form of indemnity which you claim is applicable to this accident? ___ 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.
Interrogatory No. 18: State the name, address, and occupation of the owner of any vehicles you allege caused damage to the plaintiff.
Interrogatory No. 19: At the time of the alleged accident, was the driver of said vehicle engaged in the business of any other person or entity? ___ If so, please state the name and address of such other person or entity.
Interrogatory No. 20: State whether you or anyone else involved in the accident ingested or used any drugs or medications within 48 hours prior to the accident or drank any intoxicating beverages of any kind within the 12 hours prior to the accident or to the occurrence of the accident alleged in the Complaint. ___ If so, state the times, places, amount, and type of drugs or alcoholic beverages.
Interrogatory No. 21: Do there exist any liens, including AHCCCS, Medicare, or any liens provided for by A.R.S. § 33-931 et seq., on any recovery you may have or may obtain in this matter? ___ If so, give the amount and entity holding such lien and the nature of said lien.
Interrogatory No. 22: If the accident that is the subject of the plaintiff's claim was a automobile accident, please state the following:
A. Did the vehicle which you were occupying at the time of the accident contain operational seatbelts? ___ If so, were you wearing seatbelts available for your use? ___
B. If you were not wearing the seatbelts available for your use in the vehicle at the time of the accident, set forth your reasons for failing to do so.