Bucks Cnty. C.P. Rule 4005 (c)(1)(ii)

Rule 4005(c)*(1)(ii). Standard Interrogatories.

_______ by______, attorneys, propound(s) these Interrogatories pursuant to

Pennsylvania Rules of Civil Procedure 4001 et seq. These Interrogatories are

addressed to you as a party to this action and your Answers shall be based upon

information known to you or in the possession of you, your attorney or other

representative acting on your behalf whether in preparation for litigation or

otherwise.

Each of these Interrogatories must be answered fully and completely by you in

writing and must be signed by you under oath before a Notary Public, or otherwise

properly verified.

Pennsylvania Rule of Civil Procedure 4006 requires filing and service of your

Answers on Defendant's counsel within thirty (30) days after service of these

Interrogatories.

Supplements to your Answers shall be filed in accordance with Pennsylvania Rule

of Civil Procedure 4007.4.

Unless otherwise indicated, the word "accident" refers to the occurrence stated in

plaintiff's complaint.

You will note that an original and two copies of the Interrogatories have been

served upon you. Space has been provided below each Interrogatory for your

answers. If additional space is required for answers, either use the reverse side of

said paper or attach an additional sheet of paper appropriately marking said

Interrogatory.

BY: ____________________________________________

Attorneys for

PERSONAL DATA:

l. State:

(a) Your full name.

(b) Each other name, if any, which you have used or by which you have been

known;

(c)The name of your spouse at the time of the accident; date and place of your

marriage to such spouse.

(d) Your present residence address and the address of each other residence which

you have had during the past five years.

(e) Present occupation and the name and address of your employer.

(f) Date of your birth and present age.

(g) Your Social Security number.

MEDICAL INFORMATION

2. State in detail all injuries sustained by you in the accident upon which this suit is

based.

3. Were you examined or treated by any person or institution as a result of the

accident? ____ If so, state as to each:

(a) The name and address of any hospital where you received an examination or

treatment, the dates, the nature of the treatment rendered, and the amount charged.

(b) Name and address of any person or institution which x-rayed any part of your

body, the dates and the amounts charged;

(c) the name, address and professional specialty of any person who examined or

treated you, the dates, the amounts charged, the persons findings.

4. As a result of the injuries you have described above, were you confined to bed

or your home? ____ If so, state the dates you were confined to each.

5. Have you received any medical reports from any person or institution where you

were x-rayed, examined or treated? ____ If so, attach copies of the reports to your

Answers. If you have not received any medical reports from any person or

institution where you were examined or treated for injuries sustained in the

accident or any preexisting condition, you are requested to sign the attached

"Medical Consent" form so we can obtain these reports and records. We will make

available to you all reports and records obtained by use of the Consent.

6. Did you employ any nursing service since the accident'? ____ If so, state the

name, address, period of employment, rate of pay and total amount paid for

nursing services.

7. Do you claim absence from school at any time since the accident? ____ If so,

state as to each absence:

(a) Exact dates of absence and the reasons for the absence;

(b) Name and address of the school you were attending at the time of the accident,

what grade you were then in and name and address of schools attended up to the

date of answering these Interrogatories;

(c) Whether you claim any impairment of your educational program, and, if so,

how the program was impaired;

(d) If you are claiming the absence from school or impairment of educational

program, you are requested to sign the attached "Scholastic Consent" so that we

can obtain copies of your scholastic records. We will make available to you all

scholastic records obtained by the use of the Consent.

PRESENT CONDITION

8. As to each injury from which you have fully recovered, state the approximate

date of such recovery.

9. Describe with particularity any pain, ailment, complaint, injury, scarring or

disability you presently have as a result of the accident.

10. Are you still under treatment for injuries you allege you sustained in the

accident ? ____ If so, state the full name of the person(s) treating you and the

date(s) of the last visit.

11. Are you able to perform your normal daily activities? If not, specify in what

way you are not able to perform those activities.

PREVIOUS OR SUBSEQUENT ACCIDENTS

12. Have you ever been involved in an accident of any kind before or after this

accident'? ____ If so, state:

(a) Date and place of the accident;

(b) Names of the parties to the accident;

(c) Nature of the injuries you sustained.

13. Have you ever filed a lawsuit for personal injuries? ____ If so, state to Court,

term and number of the suit and the date the suit was filed.

PRE-EXISTING CONDITIONS

14. Have you sustained any injuries or had any disease or impairment, physical or

mental, before the accident which in any way affected those parts of your body

injured in this accident? ____ If so, state:

(a) Nature of such injury, disease or impairment;

(b)Name and address of any hospital, institution, doctor or other person who

examined you;

(c) Dates of the treatment or examination.

15. Did this accident aggravate a pre-existing medical condition? ____ If so, state

the nature of the pre-existing condition and how it was aggravated.

EMPLOYMENT

16. Do you claim absence or loss of earning from employment because of the

accident? ____ If so, state for each employer:

(a) Name and address at the time of the accident;

(b) Nature of employment and usual duties:

(c) Dates of absence from employment;

(d) Date first returned to work following the accident;

(e) Rate of pay;

(f) Total amount of loss and how the sum was computed;

(g) Name and address of any person having knowledge of the above;

(h) Have you obtained any reports or records from your employer in regard to the

loss of wages and loss of earning capacity? ____ If so, attach a copy of said

records to your Answers. If you have not obtained any records, you are requested

to sign the attached "Employment Records Consent" to enable us to obtain copies

of your employment records. We will make available to you all records obtained

by use of the Consent.

17. Do you claim any loss of earning capacity or impairment of your ability to

work as a result of the accident. ____ If so, specify the nature of your claim.

18. Do you claim any loss of earnings or profits from self-employment as a result

of the accident'? ____ If so, state:

(a) Address of your usual place of employment;

(b) Name under which you did business;

(c) Nature of your self-employment;

(d) Exact dates you were unable to engage in your self-employment by reason of

the injuries sustained in the accident;

(e) Date you first resumed regular activity after the accident;

(f) Names and addresses of any employees hired as a result of your disability and

the dates of their employment;

(g) Amount you claim as lost earnings or profits and exactly how the sum is

calculated;

(h) Attach copies of all financial statements and business records upon which you

claim any lost earnings or profits.

FEDERAL TAX RETURNS

Interrogatories 19, 20 and 21 are proposed only if loss of earnings or earning

capacity is claimed.

19. State your gross and net income as stated in, our Federal Income Tax Returns

for each of the three years immediately preceding the date of the accident and for

each of the years thereafter to date.

20. Have you retained copies of your Federal Income Tax Returns for three years

before the date of the accident and for each of the years thereafter to date? ____ If

so, attach copies of, our Federal Income Tax Returns for those years.

21. If you have not retained copies of your Federal Income Tax Returns, you are

requested to sign the attached" Request for Copy of Tax Form" to enable us to

obtain copies of said records. We will make available to you all tax returns

obtained by use of the Request.

OTHER FINANCIAL LOSS

22. Do you claim any other financial losses not listed above as a result of the

accident'? ____ If so, list those items with detail as to kind, date and amount.

23. If married, does your spouse claim any financial or other loss as a result of the

accident? ____ If so, detail the kind of loss, the dates and, if applicable, to whom

money was paid.

BASIC LOSS BENEFITS

24. What is the name, address, claim number and claim representative's name of

the insurance company which insured you and/or your vehicle for Basic Loss (PIP)

Benefits at the time of the accident?

WITNESSES

25. Do you know of any person(s) you believe to be an eyewitness to the accident

or the events leading up to the accident'? ____ If so, as to each person, state:

(a) Name and present or last known address:

(b) Name and address of his/her present or last known employer:

(c) Exact location of person at time of the accident.

26. Do you know of any person(s) you believe has any knowledge of the

conditions at the scene of the accident existing before, during or immediately after

the accident other than eyewitnesses? ____ If so, as to each person, state:

(a) Name and present or last known address;

(b) Name and address of his/her present or last known employer;

(c) Exact location of person at time of the accident.

27. If not previously stated above, do you know of any person(s) you believe has

knowledge of events leading up to the accident, facts pertaining to this suit, or facts

of any investigation after the accident'? ____ If so, as to each person, state:

(a) Name and present or last known address;

(b) Name and address of his/her present or last known employer.

28. At the time of the accident or immediately thereafter, did you have any

conversation with any person at or near the scene of the accident or did any person

converse with you or in your presence relevant to the accident or injuries

sustained? ____ If so, state:

(a) Name and address of each person who spoke:

(b) Words or substance of each conversation;

(c) Name and address of any person within hearing distance of the conversation.

29. State the names and addresses of all persons who it is your intention to call as

witnesses at the trial of this case. (Other than expert witnesses.)

INVESTIGATION

30. Have you or anyone acting on your behalf obtained from any person any

report, statement, recording, memorandum or testimony, whether signed or not,

and whether prepared by someone else, concerning this accident? ____ If so, attach

copies to your Answers and state as to each person:

(a) Name and address of the witness or person from whom the item was obtained;

(b) Date the item was taken or made;

(c) Name and address of the person obtaining the item.

31. Have you ever made any report, statement, memorandum, recording or given

testimony in writing, whether prepared by you or someone else, concerning this

accident or the suit? ____ If so, attach copies at cost of interrogating party to your

Answers and state:

(a) Nature and date the item was prepared;

(b)Where the item is now located if not available to you.

32. Do you know of any photos or motion pictures, plans, drawings, blueprints,

sketches or diagrams made by anyone other than counsel regarding this occurrence

or the location of the occurrence?____ If so, attach copies at cost of interrogating

party to your Answer and state as to each item:

(a) Exact nature of the item;

(b) Date the item was made or taken:

(c) Where the item is now located if not available to you.

ACCIDENT

33. State the exact date, time and place of the accident and describe in detail how

you claim the accident occurred.

34. State in detail those facts upon which you base your claim that this defendant,

or any of the other defendants, were negligent as averred in your Complaint.

35. Do you allege any mechanical defects in a vehicle or traffic control caused or

contributed to the accident? ____ If so, state the facts upon which you rely.

36. At the time of the accident, or immediately before, did you have any temporary

or permanent impairment or restriction of vision, hearing, muscle control or other

bodily functions? ____ If so, state the details thereof.

37. At the time of the accident, or within twenty-four (24) hours prior thereto, did

you ingest any medication or alcoholic beverages? ____ If so, state the details

thereof.

38. What are the restrictions on your operator's license?

THE REMAINING INTERROGATORIES MAY BE ASKED IF APPLICABLE

PROPERTY DAMAGE

39. Did the vehicle you owned or operated at the time of the accident sustain any

damage? ____ If so, state:

(a) Name and address of the registered owner;

(b) Year, manufacturer, model and serial number of the vehicle;

(c) Your relationship to the owner of the vehicle;

(d) Parts of the vehicle you allege were damaged in the accident.

40. Has the vehicle been repaired since the accident? ____ If so, state:

(a) Name and address of the repairer;

(b) Cost of repairs and by whom paid.

41. If the vehicle has not been repaired, state:

(a) Name and address of the person(s) who prepared an estimate;

(b) Amount of the estimate(s);

(c) Attach a copy of the estimate to your Answers.

42. Was the vehicle covered by collision insurance? ____ If so, state:

(a) Name, address and claim number of the insurance company;

(b) Amount paid and the amount of any deductible.

43. Are you making any other claim for damage to property or automobile rental?

____ If so, specify the nature and amount of the claim.

EXPERT WIT'NESSES

44. If you intend to call an expert witness at trial, state:

(a) The name and address of each such expert witness;

(b) The subject matter as to which each such expert witness is expected to

testify;

(c) The substance of the facts and opinions to which each expert is expected to

testify and a summary of the grounds for each opinion and/or attach a copy of each

expert's report to your Answers to Interrogatories;

(d) The educational background, field of expertise, professional experience of each

of the expert witnesses identified in your Answers above.

TESTS

45. If any tests or procedures have or will be performed by any expert retained by

you, your attorney, consultant, surety, indemnitor, insurer or agent in this action,

whether or not you intend to call that expert witness at trial, state:

(a) The name and address of the person conducting the test, including the name of

each person's employer;

(b) The educational background, field of expertise, professional experience,

publications, membership in professional societies, employment experience and

court appearances (including citations) of each of the expert witnesses identified in

your Answers above;

(c) The location where each test or procedure was or is scheduled to be conducted;

(d) The date when each test or procedure was or is scheduled to be conducted:

(e) The result of each test or procedure completed to date:

(f) The name and address of the person currently in custody of the object tested.

(g) Attach a copy of the report of each expert identified in your Answers above.

PRODUCT DEFECT

46. Do you, your representative, attorney, consultant, surety, indemnitor, insurer or

agent have or known of any facts upon which you alleged or contend that a product

of the interrogating defendant, which is alleged to be involved in this action, was

defective? ____ If so, state:

(a) Specifically identify the product by name, number, model, etc.;

(b) State in detail and specifically the defective condition that allegedly existed;

(c) Each and every fact upon which you contend or allege said product was

defective;

(d) The name, address and job classification of all the persons known to you or to

those identified in the preamble of this interrogatory who have knowledge of such

facts and state what facts as to the alleged defectiveness of said product is within

the knowledge or possession of each of such persons;

(e) Identify each and every writing by date and author of which you know, if there

are any, which support your allegation or contention that said product was

defective.

WARRANTY

47. Do you, your representative, attorney, consultant, surety, indemnitor, insurer or

agent have or know of any facts upon which you allege or contend that the

interrogating defendant breached any warranty whatsoever to you or anyone else in

regard to the specific product of the interrogating defendant which is allegedly

involved in this action? ____ If so, please state:

(a) Each and every fact upon which you contend or allege that the interrogating

defendant breached any warranties whatsoever to you or anyone else in regard to

the specific product which is allegedly involved in this action;

(b) The name, address and job classification of all persons known to you or to

those identified in the preamble of this interrogatory who have knowledge of such

facts and state what facts as to the alleged breach of warranty is within the

knowledge or possession of each of said persons;

(c) Identify each and every writing by date and author of which you know if there

are any which support your allegation or contention that interrogating defendant

breached any warranty.

BY: ____________________________

Attorneys for