Conn. Practice Book Form 202

The undersigned, on behalf of the Defendant, hereby propounds the following interrogatories to be

answered by the Plaintiff, _______________, under oath, within sixty (60) days of the filing hereof in

compliance with Practice Book Section 13-2.

Definition: ‘‘Y ou’’ shall mean the Plaintiff to whom these interrogatories are directed except that if

suit has been instituted by the representative of the estate of a decedent, ward, or incapable person,

‘‘you’’ shall also refer to the Plaintiff’s decedent, ward or incapable person unless the context of an

interrogatory clearly indicates otherwise.

In answering these interrogatories, the Plaintiff(s) is (are) required to provide all information within

their knowledge, possession or power. If an interrogatory has subparts, answer each subpart separately

and in full and do not limit the answer to the interrogatory as a whole. If any interrogatories cannot be

answered in full, answer to the extent possible.

(1) State the following:

(a) your full name and any other name(s) by which you have been known;

(b) your date of birth;

(c) your motor vehicle operator’s license number;

(d) your home address;

(e) your business address;

(f) if you were not the owner of the subject vehicle, the name and address of the owner or lessor

of the subject vehicle on the date of the alleged occurrence.

(2) Identify and list each injury you claim to have sustained as a result of the incidents alleged in

the Complaint.

(3) When, where and from whom did you first receive treatment for said injuries?

(4) If you were treated at a hospital for injuries sustained in the alleged incident, state the name

and location of each hospital and the dates of such treatment and confinement therein.

(5) State the name and address of each physician, therapist or other source of treatment for the

conditions or injuries you sustained as a result of the incident alleged in your Complaint.

(6) When and from whom did you last receive any medical attention for injuries alleged to have

been sustained as a result of the incident alleged in your Complaint?

(7) On what date were you fully recovered from the injuries or conditions alleged in your Complaint?

(8) If you claim you are not fully recovered, state precisely from what injuries or conditions you are

presently suffering.

No. CV- : SUPERIOR COURT

(Plaintiff): JUDICIAL DISTRICT OF

VS. : AT

(Defendant): (Date)

(9) Are you presently under the care of any doctor or other health care provider for the treatment

of injuries alleged to have been sustained as a result of the incident alleged in your Complaint?

(10) If the answer to Interrogatory #9 is in the affirmative, state the name and address of each

physician or other health care provider who is treating you.

(11) Do you claim any present disability resulting from injuries or conditions allegedly sustained as

a result of the incident alleged in your Complaint?

(12) If so, state the nature of the disability claimed.

(13) Do you claim any permanent disability resulting from said incident?

(14) If the answer to Interrogatory #13 is in the affirmative, please answer the following:

(a) list the parts of your body which are disabled;

(b) list the motions, activities or use of your body which you have lost or which you are unable

to perform;

(c) state the percentage of loss of use claimed as to each part of your body;

(d) state the name and address of the person who made the prognosis for permanent disability and

the percentage of loss of use;

(e) list the date for each such prognosis.

(15) If you were or are confined to your home or your bed as a result of injuries or conditions

sustained as a result of the incident alleged in your Complaint, state the dates you were so confined.

(16) List each medical report received by you or your attorney relating to your alleged injuries or

conditions by stating the name and address of the treating doctor or other health care provider, and

of any doctor or health care person you anticipate calling as a trial witness, who provided each such

report and the date thereof.

(17) List each item of expense which you claim to have incurred as a result of the incident alleged

in your Complaint, the amount thereof, and state the name and address of the person or organization

to whom each item has been paid or is payable.

(18) For each item of expense identified in response to Interrogatory #17, if any such expense, or

portion thereof, has been paid or reimbursed or is reimbursable by an insurer, state, as to each such

item of expense, the name of the insurer that made such payment or reimbursement or that is responsible

for such reimbursement.

(19) If, during the ten year period prior to the date of the incident alleged in the Complaint, you were

under a doctor’s care for any conditions which were in any way similar or related to those identified

and listed in your response to Interrogatory #2, state the nature of said conditions, the dates on which

treatment was received, and the name of the doctor or health care provider.

(20) If, during the ten year period prior to the date of the incident alleged in your Complaint, you

were involved in any incident in which you received personal injuries similar or related to those identified

and listed in your response to Interrogatory #2, please answer the following with respect to each such

earlier incident:

(a) on what date and in what manner did you sustain such injuries?

(b) did you make a claim against anyone as a result of said accident?

(c) if so, provide the name(s) and address(es) of the person or persons against whom a claim

was made;

(d) if suit was brought, state the name and location of the Court, the return date of the suit, and the

docket number;

(e) state the nature of the injuries received in said accident;

(f) state the name and address of each physician who treated you for said injuries;

(g) state the dates on which you were so treated;

(h) state the nature of the treatment received on each such date;

(i) if you are presently or permanently disabled as a result of said injuries, please state the nature

of such disability, the name and address of each physician who diagnosed said disability and the date

of each such diagnosis.

(21) If you were involved in any incident in which you received personal injuries since the date of

the incident alleged in the Complaint, please answer the following:

(a) on what date and in what manner did you sustain said injuries?

(b) did you make a claim against anyone as a result of said accident?

(c) if so, provide the name(s) and address(es) of the person or persons against whom a claim

was made;

(d) if suit was brought, state the name and location of the Court, the return date of the suit, and the

docket number;

(e) state the nature of the injuries received in said accident;

(f) state the name and address of each physician who treated you for said injuries;

(g) state the dates on which you were so treated;

(h) state the nature of the treatment received on each such date;

(i) if you are presently or permanently disabled as a result of said injuries, please state the nature

of such disability, the name and address of each physician who diagnosed said disability and the date

of each such diagnosis.

(22) Please state the name and address of any medical service provider who has rendered an

opinion in writing or through testimony that you have sustained a permanent disability to any body part

other than those listed in response to Interrogatories #13, #14, #20 or #21, and:

(a) list each such part of your body that has been assessed a permanent disability;

(b) state the percentage of loss of use assessed as to each part of your body;

(c) state the date on which each such assessment was made.

(23) If you claim that as a result of the incident alleged in your Complaint you were prevented from

following your usual occupation, or otherwise lost time from work, please provide the following information:

(a) the name and address of your employer on the date of the incident alleged in the Complaint;

(b) the nature of your occupation and a precise description of your job responsibilities with said

employer on the date of the incident alleged in the Complaint;

(c) your average, weekly earnings, salary, or income received from said employment for the year

preceding the date of the incident alleged in the Complaint;

(d) the date following the date of the incident alleged in the Complaint on which you resumed the

duties of said employment;

(e) what loss of income do you claim as a result of the incident alleged in your Complaint and how

is said loss computed?

(f) the dates on which you were unable to perform the duties of your occupation and lost time from

work as a result of injuries or conditions claimed to have been sustained as a result of the incident

alleged in your Complaint;

(g) the name(s) and address(es) of each employer for whom you worked for three years prior to

the date of the incident alleged in your Complaint.

(24) Do you claim an impairment of earning capacity?

(25) List any other expenses or loss and the amount thereof not already set forth and which you

claim to have incurred as a result of the incident alleged in your Complaint.

(26) If you have signed a covenant not to sue, a release or discharge of any claim you had, have

or may have against any person, corporation or other entity as a result of the incident alleged in your

Complaint, please state in whose favor it was given, the date thereof, and the consideration paid to

you for giving it.

(27) If you or anyone on your behalf agreed or made an agreement with any person, corporation

or other entity to limit in any way the liability of such person, corporation or other entity as a result of

any claim you have or may have as a result of the incident alleged in your Complaint, please state in

whose favor it was given, the date thereof, and the consideration paid to you for giving it.

(28) If since the date of the incident alleged in your Complaint, you have made any claims for

workers’ compensation benefits, state the nature of such claims and the dates on which they were made.

(29) Have you made any statements, as defined in Practice Book Section 13-1, to any person

regarding any of the events or happenings alleged in your Complaint?

COMMENT:

This interrogatory is intended to include party statements made to a representative of an insurance company prior to involvement

of defense counsel.

(30) State the names and addresses of all persons known to you who were present at the time of the

incident alleged in your Complaint or who observed or witnessed all or part of the accident.

(31) As to each individual named in response to Interrogatory #30, state whether to your knowledge,

or the knowledge of your attorney, such individual has given any statement or statements as defined

in Practice Book Section 13-1 concerning the subject matter of your Complaint or alleged injuries. If

your answer to this interrogatory is affirmative, state also:

(a) the date on which such statement or statements were taken;

(b) the name(s) and address(es) of the person or persons who took such statement or statements;

(c) the name(s) and address(es) of any person or persons present when such statement or statements were taken;

(d) whether such statement or statements were written, made by recording device or taken by a

court reporter or stenographer;

(e) the name(s) and address(es) of any person or persons having custody or a copy or copies of

such statement or statements.

(32) Are you aware of any photographs or any recordings by film, video, audio or any other digital

or electronic means depicting the incident alleged in the Complaint, the scene of the incident, any

vehicle involved in the incident alleged in the Complaint, or any condition or injury alleged to have

been caused by the incident alleged in the Complaint? If so, for each set of photographs or each

recording taken, obtained or prepared of each such subject, please state:

(a) the name and address of the person who took, obtained or prepared such photograph or recording,

other than an expert who will not testify at trial;

(b) the dates on which such photographs were taken or such recordings were obtained or prepared;

(c) the subject (e.g., ‘‘Plaintiff’s vehicle,’’ ‘‘scene,’’ etc.);

(d) the number of photographs or recordings;

(e) the nature of the recording (e.g., film, video, audio, etc.).

(33) If you were the operator of any motor vehicle involved in the incident that is the subject of this

action, please state whether you consumed or used any alcoholic beverages, drugs or medications

within the eight (8) hours next preceding the time of the incident alleged in the Complaint and, if so,

indicate what you consumed or used, how much you consumed, and when.

(34) Please state whether, within eight (8) hours after the incident alleged in the Complaint, any

testing was performed to determine the presence of alcohol, drugs or other medications in your blood,

and, if so, state:

(a) the name and address of the hospital, person or entity performing such test or screen;

(b) the date and time;

(c) the results.

(35) Please identify surveillance material discoverable under Practice Book Section 13-3 (c), by

stating the name and address of any person who obtained or prepared any and all recordings, by film,

photograph, video, audio or any other digital or electronic means, of any party concerning this lawsuit

or its subject matter, including any transcript thereof which are in your possession or control or in the

possession or control of your attorney, and state the date on which each such recordings were obtained

and the person or persons of whom each such recording was made.

COMMENT:

The following two interrogatories are intended to identify situations in which a plaintiff has applied for and received workers’

compensation benefits. If compensation benefits were paid, then the supplemental interrogatories and requests for production

may be served on the Plaintiff without leave of the court if the compensation carrier does not intervene in the action.

(36) Did you make a claim for workers’ compensation benefits as a result of the incident/occurrence

alleged in the Complaint?

(37) Did you receive workers’ compensation benefits as a result of the incident/occurrence alleged

in the Complaint?

(38) If you were the operator of any motor vehicle involved in the incident that is the subject of this

action, please state whether you were using a cell phone for any activity including, but not limited

to, calling, texting, emailing, posting, tweeting, or visiting sites on the Internet for any purpose, at or

immediately prior to the time of the incident.

DEFENDANT,

BY __________________________

I, _______________, hereby certify that I have reviewed the above interrogatories and responses

thereto and that they are true and accurate to the best of my knowledge and belief.

_____________________________

(Plaintiff)

Subscribed and sworn to before me this _____________ day of ___________, 20 ___ .

_____________________________

Notary Public/

Commissioner of the Superior Court

CERTIFICATION

I certify that a copy of this document was or will immediately be mailed or delivered electronically

or non-electronically on (date) ______ to all attorneys and self-represented parties of record and that

written consent for electronic delivery was received from all attorneys exempt from e-filing and self-represented parties of record who received or will immediately be receiving electronic delivery.

Name and address of each party and attorney that copy was or will immediately be mailed or

delivered to*

*If necessary, attach additional sheet or sheets with the name and address which the copy was or

will immediately be mailed or delivered to.

________________________________________________________________________________

Signed (Signature of filer ) Print or type name of person signing Date Signed

_________________________________________________________________________________

Mailing address (Number, street, town, state and zip code) or Email address, if applicable Telephone number

HISTORY—2026: In the first sentence of the certification, “exempt from e-filing” was added after “from all attorneys.”

COMMENTARY—2026: The changes to this form are consistent with the changes to the proof of service language in Section

10-14 (a).