Free Microsoft Word - Interrog P-SF. - Hawaii

INTERROGATORIES TO PLAINTIFF (Slip/Trip/Fall)

1. State your full name, your present address, and date of birth. Answer:

2. List your occupation or job (full and/or part-time) and employers' name and address during the last five (5) years, starting with your present employer. Answer:

3. Describe in your own words, in full detail, how the incident ("incident" is defined as the accident or other event which is the subject of this claim) occurred, including the events in the five (5) minutes leading up to the incident. Answer:

4. Indicate whether you contend your slip and/or trip and/or fall resulted from: a) Slipperiness of the floor and/or walking surface and/or stair(s), and if so, due to what substance? Answer:

b) Defects in the floor and/or walking surface and/or stair(s) and/or floor covering; and if so, due to what kind of defects? Answer:

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c) Debris, litter and/or obstructions on the floor and/or walking surface and/or stair(s), and if so, due to what kind of debris, litter and/or obstructions? Answer:

d) Variations in the floor and/or walking surface and/or stairs(s), and if so, due to what kind of variations? Answer:

e) Inadequate lighting in the area, describing the lighting that was present and why you contend it was inadequate. Answer:

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f) Other defects (specify). Answer:

5. If you were wearing footwear at the time of the slip and/or trip and/or fall, please state: a) The type and brand name of the footwear; b) Where and when you purchased the footwear; c) The material of the sole and the type and height of the heel; d) The identity of the present custodian, if any, of the footwear. Answer:

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6. If you reported the condition of the area where you tripped and/or slipped and/or fell to anyone either before or after the trip and/or slip and/or fall, please indicate to whom it was reported. Answer:

7. State the names and addresses of all persons known to you or to your attorney who witnessed any part of the incident, and give a brief description of all witnesses whose names or addresses are not known. Answer:

8. Were any statements concerning the incident made to any police officer, private investigator, insurance company agent or adjuster, or anyone else? Answer:

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If so, state: a) The name, address and employer of the person to whom the statement was made; b) The date of each statement; c) Whether the statement was oral or written, and if oral, whether it was recorded; d) The name and address of the custodian(s) of each statement. Answer:

9. If you have any knowledge of any photographs, sketches, or drawings of the area where you slipped and/or tripped and/or fell, please state by whom they were made and who requested them, and who has present custody of such documents. Answer:

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10. State all physical and/or mental injuries or conditions you claim are a result of the incident. Answer:

11. State all physical and/or mental injuries or conditions you suffered from at any time before the incident. Answer:

12. State all physical and/or mental injuries or conditions you have incurred since the date of the incident which you claim either (a) aggravated your injuries, or (b) were new injuries. Answer:

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13. State the name and address of all doctors, chiropractors, hospitals, therapists and other health care providers who have rendered medical and/or other types of care for the ten (10) years before the incident to the present. Answer:

14. List all medical or health care expenses you incurred as a result of the incident. Answer:

15. If applicable, identify each insurance carrier providing medical or other health care benefits or which might provide medical or other health care benefits to you. Answer:

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16. If you are claiming any loss of earnings as a result of the incident, state the periods of time you were off work, name of employer, rate of pay, and the amount of such loss. Answer:

17. What loss of earnings, if any, do you believe you will incur in the future as a result of the accident? Answer:

InterPstf
1C-P-526 (07/07)

CLEAR

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