IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY PENNSYLVANIA
CIVIL ACTION
______________, | : | |
Plaintiff, | | : |
vs. | : | No. |
_________________,: | | |
Defendant. | : | |
DEFENDANT'S ARBITRATION DISCOVERY
REQUESTS FOR PERSONAL INJURY CLAIMS
These discovery requests are directed to _________________.
Within thirty (30) days following receipt of these requests, you shall provide the information sought in these discovery requests to every other party in this lawsuit.
IDENTITY OF PLAINTIFF(S)
1. Set forth your full name and address. WITNESSES
2. List the names, present addresses and telephone numbers (if known) of any persons who witnessed the incident (including related events before and after the incident) and any relationship between the witness and you. STATEMENTS AND OTHER WRITINGS
3.(a) Do you have any written or oral statements from any witnesses, including the defendant? Yes ____ No ____
(b) If you answered yes, attach any written statements signed, adopted or approved by any witness, attach a written summary of any other statements (including oral statements), and identify any witnesses from whom you obtained a stenographic, mechanical, electrical or other recording that has not been transcribed. (This request does not cover a statement made by a party to that party's attorney.) I have ____ have not ____ fully complied with request 3(b).
(c) Do you have any photographs, maps, drawings, diagrams, etc. that you may seek to introduce at trial? Yes ____ No ____.(d) If you answered yes, attach each of these documents. I have ____ have not ____ fully complied with request 3(c). MEDICAL INFORMATION CONCERNING PERSONAL INJURY CLAIM
4.(a) Have you received any inpatient or outpatient treatment from any hospital for any injuries or other medical conditions for which you seek damages in this lawsuit? Yes ____ No ____(b) If you answered yes, list the names of the hospitals, the names and addresses of the attending physicians, and the dates of hospitalization.(c) Have you received any chiropractic treatment for any injures or other medical conditions for which you seek damages in this lawsuit? Yes ____ No ____(d) If you answered yes, list the name and address of each chiropractor and the dates of treatment.(e) Have you received any other medical treatment not covered by the previous interrogatories for any injuries or other medical conditions for which you seek damages in this lawsuit? Yes ____ No ____ (f) If you answered yes, list the names and addresses of each physician or other treatment provider and the dates of treatment.(g) Attach complete hospital and office records covering the injuries or other medical conditions for which you seek damages for each hospital, chiropractor, and other medical provider identified in response to interrogatories 4(b), 4(d) and 4(f) or authorizations for these records. I have ____ have not ____ fully complied with request 4(g).
OTHER MEDICAL INFORMATION
5.(a) List the name and address of your family physician for the period from five (5) years prior to the incident to the present date.(b) Have you received inpatient or outpatient treatment for injuries or physical problems that are not part of your claim in this lawsuit from any hospital or medical office within the period from five (5) years prior to the incident to the present date? Yes ____ No ____(c) If you answered yes, attach a separate sheet which lists the name and address of the hospital or medical office, the date of each treatment, the reasons for the treatment, and the length of the hospitalization.(d) Have you received chiropractic treatment for injuries or physical problems that are not part of your claim in this lawsuit from any hospital within the period from five (5) years prior to the incident to the present date? Yes ____ No ____(e) If you answered yes, attach a separate sheet which lists the chiropractor's name and address, the dates of the treatment, and the reasons for the treatment.(f) Have you received any other medical treatment for injuries or physical problems that are not part of your claim in this lawsuit within the period from five (5) years prior to the incident to the present date? Yes ____ No ____(g) If you answered yes, attach a separate sheet which lists the name and address of the medical treatment provider, the dates of the treatment, and the reasons for the treatment. I have ____ have not ____ fully complied with requests 5(c), 5(e) and 5(g).
WORK LOSS
6.(a) Have you sustained any injuries which resulted in work loss within the period from five (5) years prior to the incident to the present date?(b) If you answered yes, for each injury list the date of the injury, the nature of the injury, and the dates of the lost work.7. If a claim is being made for lost income, state the following information: (a) the name and address of your employer at the time of the incident;(b) the name and address of your immediate supervisor at the time of the incident;(d) the dates of work loss due to the injuries from this alleged accident; and(e) the total amount of your work loss claim. OTHER BENEFITS
8.(a) If you are raising a claim for medical benefits or lost income, have you received or are you eligible to receive benefits from Workers' Compensation or any program, group contract, or other arrangement for payment of benefits as defined by Title 75 P.S. § 1719(b)? Yes ____ No ____(b) If you answered yes, set forth the type and amount of these benefits. INSURANCE INFORMATION
9.(a) Are you subject to the ''Limited Tort Option'' or ''Full Tort Option'' as defined in Title 75 P.S. § 1705(a) and (b)? ____ Limited Tort Option (no claim is made for nonmonetary damages)
____ Limited Tort Option (claim is made for nonmonetary damages because the injuries fall within the definition of serious injury or because one of the exceptions set forth in 75 P.S. § 1705(d)(1)-(3) applies).
____ Full Tort Option
(b) (Applicable only if you checked ''Full Tort Option''.) Describe each vehicle (make, model and year) in your household.(c) (Applicable only if you checked ''Full Tort Option.'') Attach a copy of the Declaration Sheet for the automobile insurance policy covering each automobile in your household. I have ____ have not ____ fully complied with request 9(c).
Plaintiff verifies the statements made herein are true and correct. Plaintiff understands that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsifications to authorities.
Date: _________________ _________________ Plaintiff
Amended effective 3/1/2024