Conn. Practice Book Form 218

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’’ or ‘‘your’’ shall mean the Plaintiff to whom these interrogatories are directed, except

that if a lawsuit has been instituted by the representative of the estate of a decedent, ward, or incapable

person, ‘‘you’’ or ‘‘your’’ 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) Y our full name and any other name(s) by which you have been known;

(b) Y our date of birth;

(c) Y our current home address;

(d) Y our home address as of the time of the negligence alleged in the Complaint; and

(e) Y our home address for the five years prior to and since the negligence alleged in the Complaint.

(2) State your marital status at the time of and since the negligence alleged in the Complaint and, if

married, provide the date of the marriage, the full legal name, and current address of your spouse.

(3) State the full legal name and age of each person with whom you have lived at or since the time of

the negligence alleged in the Complaint and identify each time period.

(4) State the full legal names and ages of your children. For each child, identify the time periods during

which they resided with you at or since the time of the negligence alleged in the Complaint.

(5) Identify and list each physical and mental injury or condition you claim to have sustained as a

result of the negligence alleged in the Complaint.

(6) If you were treated at a hospital for injuries and conditions sustained as a result of the negligence

alleged in the Complaint, state the name and location of each hospital and the dates of such treatment

and admission.

No. CV- : SUPERIOR COURT

(Plaintiff): JUDICIAL DISTRICT OF

VS. : AT

(Defendant): (Date)

(7) State the name and address of each physician or other health care provider who treated you for

the injuries and conditions you sustained as a result of the negligence alleged in the Complaint.

(8) When and from whom did you last receive any medical treatment for injuries and conditions alleged

to have been sustained as a result of the negligence alleged in the Complaint?

(9) Identify the date you last received medical services or treatment from the Defendant.

(10) State the date you fully recovered from the injuries and conditions alleged in your Complaint.

(11) If you are not fully recovered, state precisely from what injuries and conditions you are presently

suffering.

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

of injuries and conditions alleged to have been sustained as a result of the negligence alleged in your

Complaint?

(13) If the answer to the prior interrogatory is in the affirmative, state the name and address of each

physician or other health care provider who is treating you.

(14) Do you claim any disability resulting from injuries and conditions allegedly sustained as a result

of the negligence alleged in your Complaint?

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

(16) Do you claim any permanent disability resulting from the negligence alleged in the Complaint?

(17) If the answer to the prior interrogatory is in the affirmative, 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; and

(e) List the date for each such prognosis.

(18) If you were or are confined to your home or your bed as a result of injuries and conditions sus -

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

(19) Identify any nonprivileged medical reports received by you or your attorney relating to your alleged

injuries and conditions by stating the name and address of the treating physician or other health care

provider, and any physician or health care provider you anticipate calling as a trial witness, who provided

such reports and the date of the report.

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

in your Complaint, and state the name and address of the person or organization to whom each item

has been paid or is payable.

(21) For each item of expense identified in response to the prior interrogatory, 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.

(22) If, during the ten year period prior to the date of the negligence alleged in the Complaint, you

were under a physician’s or other health care provider’s care for any conditions which were in any way

similar or related to those identified and listed in your response to Interrogatory #5, state the nature of

said injuries or conditions, the dates you received treatment, and the name of the physician or other

health care provider who provided treatment for the prior condition.

(23) State whether you have ever filed a claim or lawsuit for physical or mental injury or condition. If

so, state the caption, venue and docket number of any such lawsuit.

(24) If you were involved in any incident in which you received physical or mental injuries or conditions

since the date of the negligence alleged in the Complaint, provide the following information:

(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 incident?

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

made;

(d) If a lawsuit was brought, state the name and location of the Court, the return date of the lawsuit,

and the docket number;

(e) State the nature of the physical or mental injuries or conditions received in said incident;

(f) State the name and address of each physician or health care provider who treated you for said

injuries or conditions;

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

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

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

disability, the name and address of each physician or health care provider who diagnosed said disability

and the date of each such diagnosis.

(25) At the time of the negligence alleged in your Complaint or thereafter, have you filed a personal

bankruptcy petition? If yes, identify the type of bankruptcy, the court and court address, caption and

docket number, name and address of trustee and whether the petition is pending or has been discharged.

(26) List all secondary schools and colleges you attended, the years attended, and degrees conferred,

if any.

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

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

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

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

preceding the date of the negligence alleged in the Complaint;

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

duties of said employment;

(e) Any loss of income you claim resulted from the negligence alleged in your Complaint and how the

loss is computed;

(f) The dates you were unable to perform the duties and lost time from work as a result of injuries or

conditions claimed to have been sustained as a result of the negligence alleged in your Complaint; and

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

of the negligence alleged in your Complaint.

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

(29) State whether you made an application(s) for life/disability insurance in the past ten years, and

if so state the date of the application(s).

(30) Identify the administrative/funeral and burial expenses incurred on behalf of the Plaintiff, if applicable, as well as the date such expenses were incurred, the recipient of such monies and the identity

of the individual who paid such expenses.

(31) If you are introducing the condition of your mental health as an element of a claim in this lawsuit,

state whether you have sought treatment with a mental health provider, including but not limited to a

psychiatrist, psychologist, therapist, or counselor, in the ten years prior to, or subsequent to the negli -

gence alleged in the Complaint.

COMMENT:

Where appropriate, and where the Plaintiff does not consent to the production of the mental health records, the Defendant

may seek a court order for the production of the records.

(32) Has any treating physician or other health care provider told you directly that the above-named

Defendant(s) failed to adhere to the acceptable standard of care in any respect?

(33) If the answer to the preceding interrogatory is in the affirmative, state the name and address of

each such physician or health care provider, the date each communication was made and the content

of any such communication.

(34) 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 negligence alleged in your

Complaint, state in whose favor it was given, the date thereof, and to the extent it is not subject to a

confidentiality agreement, the consideration paid to you for giving it. If you are unable to respond to this

interrogatory, in whole or in part, due to a confidentiality agreement, state so.

(35) If you or anyone on your behalf agreed to or contracted 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 negligence alleged in your Complaint, state in whose favor it

was given, the date thereof, and to the extent it is not subject to a confidentiality agreement, the consideration paid to you for giving it. If you are unable to respond to this interrogatory due to a confidentiality

agreement, state so.

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

negligence alleged in your Complaint or who observed or witnessed all or part of the care provided by

the Defendant.

(37) As to each individual named in response to the preceding interrogatory, 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 and conditions. 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; and

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

such statement or statements.

(38) Have you made any statements, as defined in Practice Book Section 13-1, to any person regarding any of the events alleged in your Complaint?

(39) State the name(s) and address(es) of any person(s) who you may call as a fact witness at trialof

this matter regarding the claims of damage alleged by the Plaintiff(s) in the Complaint.

COMMENT:

These individuals or witnesses shall be disclosed, except for good cause shown, no later than sixty days prior to trial and

may be thereafter deposed.

(40) Have you documented in any form any of the events, injuries, or conditions alleged in your Complaint? State whether any privilege is claimed.

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

electronic means depicting the negligence alleged in the Complaint, the care provided by the Defendant

or any injury or condition alleged to have been caused by the negligence alleged in the Complaint? If so,

for each set of photographs or each recording taken, obtained or prepared of each such subject, 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;

(d) The number of photographs or recordings;

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

(42) 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.

(43) Have you ever filed a claim/application for Social Security Disability and/or any form of government disability including military?

(44) If the answer to the preceding interrogatory is in the affirmative, state:

(a) The dates of all such applications;

(b) The reasons for seeking disability, including all listed medical conditions;

(c) How the listed medical conditions caused you to be disabled;

(d) The dates you were deemed disabled;

(e) The names and addresses of any physicians or health care providers whom you saw for disability

evaluations; and

(f) The address of any disability offices involved in obtaining such benefits.

Interrogatories #45 through #52 apply in wrongful death cases:

(45) If the decedent underwent a physical examination for any reason including, but not limited to,

examinations related to employment, or employment applications within the five (5) years prior to the

date of the negligence alleged in the Complaint, please state:

(a) The date(s) the exam was performed; and

(b) The name and address of the physician or health care provider who performed each exam.

(46) If a claim for loss of earning capacity is being made, please state the decedent’s average monthly

personal living expenses for the two (2) years preceding his/her death including, but not limited to, the

decedent’s food, rent and housing, clothing, transportation, and medical and dental care.

(47) Did the decedent suffer from any illness, injury, disease, condition, disability or defect from the

time of the negligence alleged in the Complaint to the time of death? If so, please identify the illness,

injury, disease, condition, disability or defect.

(48) If you are claiming that any preexisting physical or mental condition exacerbated, contributed to,

or accelerated the decedent’s death, identify the condition(s) and physician or health care provider(s)

treating the decedent for those condition(s) in the ten years prior to his or her death.

(49) Other than what is contained in the medical records, are you aware of any treating physician,

physician’s assistant (P .A.), or advanced practice registered nurse (APRN) who discussed the primary

cause of the decedent’s death with a patient representative? If so, please identify that individual and the

substance of that conversation.

(50) Was an autopsy and/or postmortem toxicology testing ever performed on the decedent? If the

answer is yes, state:

(a) The name of the person who ordered or requested the autopsy;

(b) The date the autopsy was performed;

(c) The place where the autopsy was performed;

(d) The name of the individual who performed the autopsy; and

(e) The findings of the autopsy and/or postmortem toxicology testing.

(51) Have any entries, memoranda, and/or declarations, as defined in General Statutes § 52-172,

been made by the Plaintiff concerning the issues alleged in the Complaint?

(52) If the answer to the foregoing interrogatory is affirmative, state:

(a) The date on which such entries, memoranda, and/or declarations were made;

(b) The form of the entries, memoranda, and/or declarations (i.e., whether oral, written, made by

recording device or recorded by a stenographer, etc.);

(c) The substance or content of such entries, memoranda, and/or declarations;

(d) The name and address of each person having custody or a copy or copies of the entries, memoranda, and/or declarations; and

(e) The name and address of any witnesses to such entries, memoranda, and/or declarations.

Interrogatory #53 applies to cases involving a minor Plaintiff:

(53) If the minor Plaintiff attends or has attended a day care, preschool, school or camp on a regular

basis from the time of the negligence alleged in the Complaint to the present time, state:

(a) The name and address of the institution or facility;

(b) The amount of time each day that the minor Plaintiff attended there; and

(c) The dates of attendance.

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).