INTRODUCTION:

Self, under oath, need verbal response, advise if don???t understand a question

Taking any medications, under influence of alcohol

PERSONAL:

Name (known by any other names, alias)

Date of Birth

Social Security Number

ADDRESSES:

Current address

– How long at said address

– Who lives with you

Address of time of accident

– Who lived with you at that time

– Did anyone else living with you have a motor vehicle

– If so, was it insured

– by whom

– Who pays the bills (rent, light, electric, water, etc.)

– Were the other occupants of the house employed at the time of the accident

– if so, with whom

Prior addresses-same questions as above

MARRIAGE:

When, where and how long

– Children of the marriage

_ Spouse employed

– know anything about the accident, if so, what

Prior marriages-same questions as above

CHILDREN:

Name, current address, address at time of accident, age, marital status

Employment

Know anything about the accident, if so, what

GRANDCHILDREN:
Same as above

EDUCATION:

Last grade completed

College/Graduate courses

Technical training

Degrees earned

Professional associations, if applicable

MILITARY SERVICE:

Branch & rank

Job duties

Kind of discharge

Seen by V.A. doctors

SOCIAL LIFE:

Church affiliations-position with church-pastor-close friends

Clubs-position held-close friends (names, address, work place)

Activities-what kind-how often-other participants

Hobbies, pastimes, sports-same as above

Did you participate in sports before the accident

???If so, what kind of sports

???How often

???Where do you play

???Names and addresses of other participants or team members

???Tournaments or trophies won

???When was the last time you participated in such sports

???Effect of injuries on participation in said sports

EMPLOYMENT HISTORY:

Most recent job:

-Position, duties

-Date hired, date left, if applicable

-Salary, raises, promotions

-Supervisor ??? presently, at the time of the accident

-Co-workers ??? names, addresses, their position, length known them

TERMINATION/Reason ??? give names, addresses of supervisors and whether person still there

Limitations of work ??? before accident, after

Use of sick leave for this accident

Job held at time of accident; Same questions as above

Prior jobs: Same questions as above

PRIOR ACCIDENTS:

AUTOMOBILE ACCIDENTS:

When, where and parties involved

Description of how accident occurred

Who was at fault???any tickets issues

Vehicle-owner, insurer, damage, currently own said vehicle

Injuries: -to you

-to passengers/your vehicle

-to other driver, passengers/his vehicle

Doctors-names, addresses, type of physicians

Limitations sustained after the accident

-if so, for how long

-have your complaints and limitations since resolved themselves

Any psychological treatment as a result of that accident

-if so, with what doctor, type of treatment and for how long

Complaints-still under doctor???s care-reoccurring symptoms

Diagnosis???permanency rating given

Medications prescribed: by whom; why; dosage; duration; Currently taking the medication-if so, duration/termination of dosage

Consult an attorney-who, when, result

Compensation received-how much, when, from whom

Any other accidents???same questions

WORKERS??? COMPENSATION CLAIM:

When, where, benefits received/still receiving

With whom did you file

-at work

-with the workers??? compensation carrier

Case agent, name and address

File number or claim number, if known

Still receiving benefits

OTHER NON-MV RELATED ACCIDENTS: (i.e., broken bones, slip and falls, etc.)

When, where

Description of how accident occurred

Job related injury: if so, file workers??? compensation claim-

same questions as above

Injuries received

Doctors-same questions as above

Medications prescribed: same questions as above

Consult an attorney-same questions as above

Compensation received-same questions as above

PRIOR VIOLENT CRIMES:

Ever been a victim of

Any injuries as a result

-what

-where treated, doctor

-medications

-residual effects

Details of violent crimes

-when, where, what agency investigated

-case prosecuted

-any restitution ordered/paid

-judges name

-case number

-sentence of criminal defendant

PRIOR MEDICAL HISTORY:

Family Doctor(s): Name, address, how long, previous family doctors

Prior Medical Illness:

-When

-Describe, length of illness

-Doctors seen, still under doctor???s care

-Reoccurring, symptoms or limitations or restrictions

-ANY OTHER ILLNESS

How Medical Bills Were Paid

-workers??? compensation claim-benefits received

PRIOR SURGERIES:

-Hospital, Surgeon???s name, type of operation

-Length of stay in the hospital

-Date of surgery

-Follow-up care, still under doctor???s care,

-Reoccurring symptoms, medicines prescribed

-Limitations or restrictions as a result of said surgery

-ANY OTHER SURGERIES

-if so, same questions as above

Payment of Medical Bills, Lawsuits, Workers??? Compensation Claim

Did you retain an attorney to represent you in that case

-if so, what is the name of the attorney

LIMITATIONS BEFORE THE ACCIDENT:

Describe limitations and origin of limitations

Effect on Lifestyle

Medications prescribed-same questions as in prior accident section

Allergies: Cause of allergy, limitations of lifestyle, medications prescribed

DRIVER???S LICENSE:

Were you driving at the time of the accident

May I see your Driver???s License,

Place number on the record

Make copy of license and attach as an exhibit

Was your license valid at the time of the accident

What type of license did you have

Any restrictions

Has your license ever been suspended or revoked

If so, When

How many times

For what reason

Any other driving ticket or offenses

If so, When

What type of offense or ticket

Disposition (i.e., went to court, result; pay fine; go to school, when, where)

IF DRIVER, INSURANCE INFORMATION ON HIS VEHICLE:

Company name, agent, type of insurance

Payments by the insurance company

ACCIDENT:

Day, date, time

Weather conditions

Traffic conditions

DRIVING CONDITIONS-windows up or down, radio or tape player on, talking with passengers, any other possible distractions

Familiarity with route

Vehicle-describe, driver/passenger,

-Insurer

-Prior mechanical problems, brakes/lights/signals operational

-Safety equipment, et SIDE MIRRORS, existence and use of that equipment

What role that equipment had during accident

Passenger(s):

-in your car-name(s), age, address, date of birth

-how long have you known them, in what capacity

-when first met up with the passengers on the date of the accident

-what everyone did before accident

-ANY DRINKING INVOLVED, if so

-what did you drink, beer or liquor or both

-how many

-time began drinking

-time ended drinking

???what did the other people who went with you h ave to drink

???list their name and address

???were those people with you the entire time

???other people who were present during the above times that were not involved in the MVA

???where did you go drinking, name and address of the bar

???have you been there before

???name of bartender, waitress or other service personnel at the bar

???have the above people seen you or waited on you before

???have the above people seen you or waited on you since the accident

???when was the last time you saw them

???did you see friends at the bar or people you knew

-if so, their name and address

-did you go to any other drinking establishments after you left

-where did you go after you left

-what route did you take

-who drove

-where located in the car

-were they wearing seatbelts, statements of passengers, etc.

-seen them since the MVA, what discussion about the accident, injuries, etc

SEATBELT-operational, type of belt worn (i.e., lap strap or shoulder harness)

-who was wearing one

-type of seatbelts worn by passenger

Other Vehicles involved in the accident-describe vehicle, name of insurer

-Driver(s)/passenger(s)-names, addresses, any other pertinent information

-Location of other vehicles throughout incident

DESCRIBE HOW THE ACCIDENT OCCURRED:

Location, road conditions, any construction underway,

How often did you travel said road

Direction of your travel, direction of adverse driver(s) travel

Physical description of area-location of lights; stop signs; cross walks; sidewalks

ANYTHING THAT WOULD OBSTRUCT ANY PARTIES??? VIEW

DRAW A DIAGRAM. ATTACH TO DEPOSITION AS EXHIBIT

Describe accident, location of other vehicle

Any efforts made by other parties to avoid MVA

Did you see the driver of the other vehicle

???if so, describe the driver

(male/female, race, hair color, eye color, etc.)

have you seen the driver since

Did the driver say anything to you

What was the physical condition of the driver ??? coherent,

awake, under the influence, etc.

What was the mental condition of the driver ???eg aggressive, combative, cooperative, etc.

POINT OF IMPACT

Skid marks, other evidences of accident

Resting places of the vehicles involved

Debris on the road after accident

how vehicles removed from the scene

Witnesses-name, address, work, any other information

Police: when arrived, name and address of officers

Statements made, written report

???what did you tell them

???what did the other parties, witnesses, etc. to the accident tell them

TICKETS-any issued-to whom, for what; disposition of ticket, citing officer(s)

Witnesses: name, address, employment, statements given

(if so, to whom),

-content of statement, place where witness was located

-what they saw

Injuries: describe seating position

Location of injuries (head, neck, shoulder, legs, etc.)

Origin of injuries (objects you struck); extent of injuries (bleeding, broken bones)

Injuries to others-same questions as above

Rescue- who called, arrival time, anyone transported-to what hospital, blood drawn
Anyone else taken to the hospital

Statements:

Person???s name and address, when made/to whom; contents of statement(s), witness(es)

People you???ve spoken with regarding this accident;

content of discussion

Damage to vehicles-when, where

Extent of damages, vehicle(s) operational after accident

Photos taken of the vehicle(s)-if so, when, where, by whom

MEDICAL TREATMENT:

When, for what complaints

Doctor(s);

Name, address, type of physician, date(s) seen, frequency and length of care

Who referred you to that doctor

Type of care given

Diagnosis ??? medications, physical therapy ??? surgery, if so, when, why, results of surgery;

Permanency rating given???our understanding of permanency

Limitations given by Doctor if any

LAST TIME SAW DOCTOR

ANY INTENT TO RETURN

Referrals to other physicians

Supportive Devices???BOTH before and after the accident

Type of device use (e.g., wheelchair, crutches, cane, etc.)

Length used device

Last time used such device

If currently using one of the devices, how often

Tests:

Type, when performed

Prescribed by whom

Location where administered, procedure, name of person who conducted the tests

Results, who ???read??? (interpreted) the results

Physical Therapy

Who recommended it

Where administered, name of therapist

Describe activities engaged in, frequency of attendance

Still undergoing PT

Medications-same questions as above

Surgery/Hospitalizations

-any future surgeries recommended

-length of surgery, cost of surgery

-success of surgery,

LAST DATE OF MEDICAL TREATMENT:

Any intentions of returning to see a physician, if so

???Which physician

???Date of next visit

PSYCHIATRIC/PSYCHOLOGICAL TREATMENT:

For what

Who recommended

Doctors or psychiatrists seen, how referred to that person

Treatment prescribe

-frequency and length treatment

-diagnostic tests given

-other tests given, describe, who administered it

-results (or your understanding of results)

Last visit

Cost of treatment

Referral to other doctors, etc.

Any intentions to obtain further treatment

LIMITATIONS:

In your movement???On your activities and daily live

Any improvement since the accident

DAMAGES:

Property damage

Medical expenses- incurred, outstanding and unpaid, insurance liens, surgical costs

Insurance-company name, policy limits, type of coverage, PIP exhausted, MPC exhausted

UM coverage, bills submitted but unpaid

Wages-past lost wages, estimate of future lost wages, sick leave

Lawsuit: Attorney consulted-name, address, date of initial consultation

SUBSEQUENT ACCIDENTS:
Same Questions As Prior Accidents

VACATIONS OR TRIPS OUT OF TOWN IN THE LAST FEW YEARS:

PHYSICAL DATA:

Height, weight-before accident, after accident, present

Smoking habit-how many packs a day, length of habit

Alcohol-how often; drinking day of accident, if so, how much; ever had treatment or rehabilitation

Prior Arrests-when, where, for what, adjudication imposed, sentence imposed

-Felony Convictions

-How many times

-For what

-When???month, year

-What city, town, county and state

-Convictions involving dishonesty, e.g., petty theft, perjury???both are misdemeanors

-How many times

-For what

-When???month, year

-What city, town, county and state

-Arrests/Pending charges ??? discovery and am entitled to ask Qs which may lead to relevant information ??? if continue to object, certify the question