Courtesy of RosenfeldInjuryLawyers.com (888)
|
|
|
- Horatio Ward
- 8 years ago
- Views:
Transcription
1 1. State the full name of the Defendant answering, as well as your current residence address, date of birth, marital status, driver's license number and issuing state, and social security number, and, if different, give the full name, as well as the current residence address, date of birth, marital status, driver's license number and issuing state, and social security number of the individual signing these answers. ANSWER: Cortez Robinson, 8355 S. St. Lawrence, Chicago, Illinois; Date of Birth: XX/XX/69; Driver's License Number: XXXXXXXXXXXXXX IL; last four digits of Social Security Number: 1652; marital status: Single. 2. State the full name and current residence address of each person who witnessed or claims to have witnessed the occurrence that is the subject of this suit. ANSWER: None other than the parties to the lawsuit and the individuals that may be indicated on the police report, investigation continues. 3. State the full name and current residence address of each person not named in Interrogatory No. 2 above who was present and/or claims to have been present at the scene immediately before, at the time of and/or immediately after said occurrence. 4. As a result of the occurrence, were you made a Defendant in any criminal or traffic case? If so, state the court, the caption, the case number, the charge or charges filed against you, and whether you pleaded guilty thereto and the final disposition. 5. Were you the owner and/or driver of any vehicle involved in the occurrence? If so, state whether the vehicle was repaired and, if so, state when, where, by whom, and the cost of said repairs. ANSWER: Yes; yes; 2 weeks after accident; garage; my mechanic; about $ Were you the owner and/or driver of any vehicle involved in said occurrence? If so, were you named or covered under any policy of liability insurance effective on the date of said occurrence and, if so, state the name of each such company, the policy number, the effective period and the maximum liability limits for each person and each occurrence, including umbrella or excess insurance coverage, property damage and medical payment coverage. ANSWER: Yes, I am the owner, and I believe I was covered under United Auto Insurance policy number with effective dates of 8/4/05 to 8/4/06 and limits of 20/40/ Do you have any information tending to indicate: (a) That any plaintiff was, within the five years immediately prior to said occurrence, confined in a hospital, treated by a physician or x-rayed for any reason other than personal injury? If so, state each plaintiff so involved and give the name Courtesy of RosenfeldInjuryLawyers.com (888)
2 and address of each such hospital, physician, technician or clinic, the approximate date of such confinement or service and state, in general, the reason for such confinement or service. (b) That any plaintiff had suffered serious personal injury prior to the date of said occurrence? If so, state each plaintiff so involved and state when, where and in general how he or she was injured and describe in general the injuries suffered. (c) That any plaintiff has suffered either (a) any personal injury or (b) serious illness, since the date of said occurrence? If so, state each plaintiff so involved and, for (a) state when, where and in general how he or she was injured and describe in general the injuries suffered; and for (b) state when he or she was ill and describe in general the illness. (d) That any plaintiff has ever filed any other suit for his or her own personal injuries? If so, state each plaintiff so involved and give the court in which filed, the year filed and the title and docket number of said case. ANSWER: (a) - (d) None other than the information previously submitted by the attorney for the plaintiff. 8. Were any photographs, movies and/or videotapes taken of the scene of the occurrence or of the persons and/or vehicles involved? If so, state the date or dates on which photographs were taken, the subjects thereof and who now has custody of them, and the name, address and occupation and employer of the person taking them. 9. Have you (or anyone acting on your behalf) had any conversations with any person at any time with regard to the manner in which the occurrence complained of occurred, or have you overheard any statements made by any person at any time with regard to the injuries complained of by plaintiff or the manner in which the occurrence complained of occurred? If the answer to this Interrogatory is in the affirmative, state the following: a. The date or dates of such conversations and/or statements; b. The place of such conversations and/or statements; c. All persons present for the conversations and/or statements; d. The matters and things stated by the person in the conversations and/or statements; and e. Whether the conversation was oral; written and/or recorded; f. Who has possession of the statement if written and/or recorded. ANSWER: None other than at the scene of the occurrence, investigation continues. 10. Do you know of any statements made by any person relating to the occurrence complained of by the plaintiff? If so, give the name and address of each such witness, the date of said statement, and state whether such statement was written and/or oral. Courtesy of RosenfeldInjuryLawyers.com (888)
3 11. Had you consumed any alcoholic beverage within 12 hours immediately prior to said occurrence? If so, state the names and addresses of those from whom it was obtained, state where it was consumed, and state the particular kind and amount of alcoholic beverage so consumed by you, and state the names and current residence addresses of all persons known by you to have knowledge concerning the consumption of said alcoholic beverages. 12. Have you ever been convicted of a misdemeanor involving dishonesty, false statement or felony? If so, state the nature thereof, the date of conviction, and the court and the caption in which the conviction occurred. For the purpose of this interrogatory, a plea of guilty shall be considered as a conviction. ANSWER: Yes; drugs in Had you used any drugs or medications within 24 hours immediately prior to said occurrence. If so, state the names and addresses of those from whom it was obtained, state where it was used, and state the particular kind and amount of drug or medication so used by you, and state the names and current residence addresses of all persons known by you to have knowledge concerning the use of said drug or medication. 14. Were you employed on the date of the occurrence? If so, state the name and address of your employer, and the date of employment and termination, if applicable. If you answer is in the affirmative, state the position, title and nature of your occupational responsibilities with respect to your employment. ANSWER: Yes; AOL Time Warner, 25 E. Washington, Chicago, Illinois; April October, 2006; Sales Manager/Trainer. 15. What was the purpose and/or use for which the vehicle was being operated for at the time of said occurrence? ANSWER: Family car. 16. State the names and addresses of all persons who have knowledge of the purpose for which the vehicle was being used for at the time of said occurrence. ANSWER: Tamie Lamb, 7552 S. Emerald; Leesa Binion, 8037 S. Evans. 17. State the name and address of the registered owner of each vehicle involved in said occurrence. ANSWER: See Police Report, investigation continues. 18. Have you ever had your driver's license suspended and/or revoked? If so, state whether it was suspended and/or revoked, the date it was suspended and/or revoked, the reason for the suspension and/or revocation, for what period of time was it suspended and/or revoked, and the state that issued the license. Courtesy of RosenfeldInjuryLawyers.com (888)
4 19. Do you have or have you had any restrictions on your driver's license? If so, state the nature of the restrictions. 20. Do you have any medical and/or physical condition, which required a physician's report and/or letter of approval in order to drive? If so, state the nature of the medical and/or physical condition, the physician or other health care professional who issued the letter and/or report, and the names and addresses of any physician or other health care professional who treated you for this condition prior to the occurrence. 21. State the name and address of any physician, ophthalmologist, optician or other health care professional who performed any eye examination of you within the last five years and the dates each such examination. ANSWER: D.M.V., 99th & King Drive. 22. State the name and address of any physician or other health care professional who examined and/or treated you within the last 10 years and the reason for such examination and/or treatment. ANSWER: Not applicable. 23. Pursuant to Illinois Supreme Court Rule 213(f), provide the name and address of each witness who will testify at trial and all other information required for each witness. ANSWER: The parties to this lawsuit may testify as to their personal knowledge of the facts of automobile accident which forms the basis of this lawsuit including facts pertinent to liability and facts pertinent to damages claimed by the plaintiff and including any statements by the parties. The parties and the persons listed on the police report will testify to the pre-occurrence and post-occurrence facts, including but not limited to the configuration of the accident scene, the directions, and locations of the vehicles involved, speeds, times, and distances, the severity of the impact(s), the points of impact, the amount of property damage observed to the vehicles after the accident, the position of the vehicles after the accident, visual observations regarding the plaintiffs injuries and the plaintiffs complaints of injury at the scene of the occurrence; their testimony is expected to be consistent with their depositions. All other previously disclosed individuals; subject matter, liability and damages. The defendant reserves the right to disclose and call additional opinion witnesses at a later date. 24. Pursuant to Illinois Supreme Court Rule 213(g), provide the name and address of each opinin witness who will offer any testimony and state: a. The subject matter on which the opinion witness is expected to testify; Courtesy of RosenfeldInjuryLawyers.com (888)
5 b. The conclusions and/or opinions of the opinion witness and the basis therefore, including reports of the witness, if any; c. The qualifications of each opinion witness, including a curriculum vitae and/or resume, if any; and d. The identity of any written reports of the opinion witness regarding this occurrence. ANSWER: All previously disclosed individuals regarding issues of liability and alleged injuries and damages. The parties and the individuals indicated on the police report regarding issues of liability and alleged injuries and damage; the investigating police officer regarding issues of liability and alleged injuries and damages (see police report). 25. List the names and address of all other persons (other than yourself and persons heretofore listed) who have knowledge of the facts of said occurrence and/or of the injuries and damages claimed to have resulted therefrom. ANSWER: My attorneys. Courtesy of RosenfeldInjuryLawyers.com (888)
IN THE CIRCUIT COURT OF WILL COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION INTERROGATORIES TO DEFENDANT, WERNER ENTERPRISES
IN THE CIRCUIT COURT OF WILL COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION JOHN DOE, Plaintiff, v. No. 10-L- JIM TRUCKER, and TRUCKING COMPANY, INC. Defendants. INTERROGATORIES TO DEFENDANT, WERNER
IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI., ) Plaintiff, ) Case No. v. ) ), ) Defendant. )
TO PLAINTIFF IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI, ) Plaintiff, ) Case No. v. ) ), ) Defendant. ) DEFENDANT S FIRST INTERROGATORIES DIRECTED TO PLAINTIFF Comes now defendant, and in
IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI., ) Plaintiff, ) Case No. v. ) ), ) Defendant. )
IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI, ) Plaintiff, ) Case No. v. ) ), ) Defendant. ) PLAINTIFF S FIRST INTERROGATORIES DIRECTED Comes now plaintiff, and in accordance with the Missouri
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI ) ) ) ) ) ) ) ) ) PLAINTIFF'S INTERROGATORIES DIRECTED TO DEFENDANT
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI, Plaintiff, vs., Defendant. Cause No. Division No. PLAINTIFF'S INTERROGATORIES DIRECTED Comes now plaintiff and, in accordance with the Missouri
IN THE CIRCUIT COURT OF CHRISTIAN COUNTY, MISSOURI
IN THE CIRCUIT COURT OF CHRISTIAN COUNTY, MISSOURI JOHN DOE, ) ) Plaintiff, ) ) vs. ) ) Case Number: 11CT-******** JANE DOE, ) ) and ) ) INSURANCE COMPANY ) ) Defendants. ) PLAINTIFF S FIRST INTERROGATORIES
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA NO.
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA PLAINTIFF(S) v. DEFENDANT(S) CIVIL TRIAL DIVISION Compulsory Arbitration Program COURT TERM: NO. Plaintiff(s) Interrogatories
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COURT TERM: NO.
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA PLAINTIFF(S) v. DEFENDANT(S) CIVIL TRIAL DIVISION Compulsory Arbitration Program COURT TERM: NO. Defendant s Interrogatories
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION PLAINTIFF S FIRST SET OF INTERROGATORIES TO DEFENDANT, XXXXX XXXXX XXXX.
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION INJURED PARTY, Plaintiff, vs. No: 00 L 0000 XXXXX XXXXX XXXXX XXX., Defendant. PLAINTIFF S FIRST SET OF INTERROGATORIES TO
Plaintiff s Interrogatories Directed To Defendant(S)
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY PLAINTIFF S NAME : Civil Trial Division : : Compulsory Arbitration Program : vs. : : Term, 20 : DEFENDANT S NAME
INSTRUCTIONS FOR USE
Uniform Personal Injury Interrogatories INSTRUCTIONS FOR USE A. All information is to be divulged which is in the possession of the individual or corporate party, his attorneys, investigator, agents, employees,
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI., ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant.
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI, ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. ) DEFENDANT S INTERROGATORIES DIRECTED TO PLAINTIFF COMES NOT defendant,
Defendant s Interrogatories Addressed to Plaintiff(s) Motor Vehicle Liability Cases
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY PLAINTIFF S NAME : Civil Trial Division : : Compulsory Arbitration Program : vs. : : Term, 20 : DEFENDANT S NAME
APPENDIX II. INTERROGATORY FORMS
APPENDIX II. INTERROGATORY FORMS Form A. Uniform Interrogatories to be Answered by Plaintiff in All Personal Injury Cases (Except Medical Malpractice Cases): Superior Court All questions must be answered
, ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. ) PLAINTIFF S INTERROGATORIES DIRECTED TO DEFENDANT
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI, ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. ) PLAINTIFF S INTERROGATORIES DIRECTED TO DEFENDANT Comes now plaintiff,
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION ) ) ) ) ) ) ) ) ) ) ) ) ) ) No.
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION INJURED PERSON, Plaintiff, v. RESPONSIBLE PARTY Defendant. No. PLAINTIFFS FIRST SET OF INTERROGATORIES TO DEFENDANT RESPONSIBLE
Defendant s Interrogatories Addressed To Plaintiff Premises Liability Cases
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY PLAINTIFF S NAME : Civil Trial Division : : Compulsory Arbitration Program : vs. : : Term, 20 : DEFENDANT S NAME
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION PLAINTIFF S FIRST SET OF INTERROGATORIES TO DEFENDANTS
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, LAW DIVISION INJURED PERSON, ) ) Plaintiff, ) ) v. ) Case No.: ) RESPONSIBLE PARTIES ) ) Defendants. ) PLAINTIFF S FIRST SET OF INTERROGATORIES
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY TRIAL DIVISION ADMINISTRATIVE DOCKET No. 2005-02 In re: Standard Interrogatories In Compulsory Arbitration Cases
No. 77,020. [April 4, 19911
No. 77,020 IN RE: AMENDMENT TO RULES OF CIVIL PROCEDURE - FORM 1.976 STANDARD FORMS FOR INTERROGATORIES [April 4, 19911 PER CURIAM. The Civil Procedure Rules Committee of The Florida Bar, responding to
INTERROGATORIES TO DEFENDANT (Slip/Trip/Fall)
INTERROGATORIES TO DEFENDANT (Slip/Trip/Fall) 1. Please state your full name, your present home address, your employer s name and business address, and the title you hold with the named defendant, or the
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI., ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant.
IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI, ) ) Plaintiff, ) ) Cause No. vs. ) ) Division No., ) ) Defendant. ) PLAINTIFF S INTERROGATORIES DIRECTED TO DEFENDANT Comes not plaintiff,
IN THE CIRCUIT COURT OF GREENE COUNTY, MISSOURI
IN THE CIRCUIT COURT OF GREENE COUNTY, MISSOURI JANE DOE, ) ) Plaintiff, ) ) vs. ) ) Case Number 1131-********* MISSOURI COMPANY, ) ) and ) ) INDIANA COMPANY ) ) Defendants. ) PLAINTIFF S FIRST INTERROGATORIES
PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE
PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE TODAY S DATE: PERSONAL INFORMATION: NAME: (home) (cell) Age: Date of Birth: Social Security No: EMPLOYER: (work) Occupation: Worked there how long? Immediate
BARROW COUNTY SUPERIOR COURT STATE OF GEORGIA * * * * * * * * * * SUMMONS CASE NO.:
BARROW COUNTY SUPERIOR COURT SHELDON ALLEN Plaintiff, vs. MATTHEW BENNETT, Defendant. STATE OF GEORGIA SUMMONS JURY TRIAL DEMANDED CASE NO.: TO THE ABOVE NAMED DEFENDANT: You are hereby summoned and required
How To Tell Someone You Were Injured In A Car Accident
Personal Injury Questionnaire Answer each question fully and accurately. Success in this case depends on mutual confidence and complete cooperation between you (as the client) and the attorney. It is imperative
Sample Pleadings in a Auto Accident Case
Civil Procedure for R.I. Paralegals First Edition - 2000 Printing Sample Pleadings in a Auto Accident Case The following documents are designed to show the kinds of pleadings that may arise in a civil
IN THE CIRCUIT COURT OF GREENE COUNTY, MISSOURI
IN THE CIRCUIT COURT OF GREENE COUNTY, MISSOURI JANE DOE INDIVIDUALLY ) and on BEHALF OF ) THE CLASS OF PERSONS ) DESIGNATED BY 537.080, ) ) Plaintiff, ) ) Case Number *************** vs. ) ) DEFENDANT
2. EDUCATION AND TRAINING Please provide the extent of your education, course of study, degrees obtained, and when obtained.
UNIFORM FAMILY LAW INTERROGATORIES BACKGROUND AND PERSONAL HISTORY 1. NAME AND CONTACT INFORMATION State your full name, current residence, telephone number, social security number, and date of birth;
COBB COUNTY STATE COURT STATE OF GEORGIA * * * * * * * * * * SUMMONS CASE NO.:
COBB COUNTY STATE COURT STATE OF GEORGIA GEORGE LOUIS BAILEY, Plaintiff, vs. MARVIN SIMPSON, Defendant. SUMMONS JURY TRIAL DEMANDED CASE NO.: TO THE ABOVE NAMED DEFENDANT: You are hereby summoned and required
1. Set forth the following information as to the decedent:
vs. Plaintiff, Defendant. SUPERIOR COURT OF NEW JERSEY LAW DIVISION Docket No.: Civil Action WRONGFUL DEATH INTERROGATORIES TO: Plaintiff,, provides the following answers to Defendant s Wrongful Death
SUPREME COURT OF ARIZONA
SUPREME COURT OF ARIZONA In the Matter of ) Arizona Supreme Court ) No. R-07-0022 PETITION TO AMEND RULE 33.1 OF ) THE RULES OF CIVIL PROCEDURE, ) ITS COMMENTS AND THE UNIFORM ) INTERROGATORIES FORMS )
CLIENT INTERVIEW FORM AUTO ACCIDENTS
CLIENT INTERVIEW FORM AUTO ACCIDENTS Please fill out the following form to the best of your ability. YOUR INFORMATION First Name: MI: Last Name: Drivers License #: Date of Birth: Email Phone (work): State:
THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) PERSONAL INFORMATION:
THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) TODAY'S DATE PERSONAL INFORMATION: DATE OF ACCIDENT NAME HOME ADDRESS CITY STATE ZIP HOME TELEPHONE ( ) DATE OF BIRTH
Case No. PRELIMINARY STATEMENT
Full Name of Party Filing Document Mailing Address (Street or Post Office Box) City, State and Zip Code Telephone IN THE DISTRICT COURT FOR THE FOR THE STATE OF IDAHO, IN AND FOR THE COUNTY OF JUDICIAL
ACCELERATED REHABILITATIVE DISPOSITION APPLICATION
OFFICE OF THE WARREN COUNTY DISTRICT ATTORNEY WARREN COUNTY COURT HOUSE 204 Fourth Avenue WARREN, PENNSYLVANIA 16365 Phone 814-728-3460 FAX 814-728-3483 ACCELERATED REHABILITATIVE DISPOSITION APPLICATION
INITIAL CLIENT STATEMENT
PERSONAL INJURY/AUTO ACCIDENT INTAKE SHEET SOL: INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY: DO YOU HAVE A SIGNED RELEASE BY THAT ATTORNEY?
HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? WHO WERE YOU REFERRED BY: (INDIVIDUAL, YELLOW PAGE AD, ETC...) Email Address:
PERSONAL INJURY/AUTO ACCIDENT INTAKE SHEET SOL: INITIAL CLIENT STATEMENT TODAY S DATE: HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY : DO YOU HAVE A SIGNED RELEASE
PERSONAL INJURY INTAKE SHEET
PERSONAL INJURY INTAKE SHEET PERSONAL INFORMATION Client's Name Aliases Date Phone H W SSN Race Sex Age DOB Marital Status M S D Resides With List addresses where client has resided during the past 10
Compulsory Arbitration
Local Rule 1301 Scope. Compulsory Arbitration Local Rule 1301 Scope. (1) The following civil actions shall first be submitted to and heard by a Board of Arbitrators: (a) (b) (c) (d) Civil actions, proceedings
CLAIM FORM AND BODILY INJURY/WRONGFUL DEATH CLAIM QUESTIONNAIRE
CLAIM FORM AND BODILY INJURY/WRONGFUL DEATH CLAIM QUESTIONNAIRE Claimant s Name: Address: City/State: Attorney s Name: Firm: Address: Phone: City/State Phone: * Should you require additional space in responding
Physician Assistant Application for Professional Liability Insurance Additional Insured Basis*
Physician Assistant Application for Professional Liability Insurance Additional Insured Basis* IMPORTANT INSTRUCTIONS PLEASE READ CAREFULLY *Coverage on an Additional Insured Basis provides coverage only
Volunteer Driver Application Form
Road to Recovery Volunteer Driver Application Form Please Print Name: Street Address: City State Zip: Other Address Information/ Email: Home Phone: Work Phone: Date of Birth: Occupation: Emergency Contact
CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL
CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL 1. Full Name: 2. Other Names Known By: 3. Address: 4. Home Phone: Work Phone: 5. Date of Birth: Age: 6. Social Security Number: 7. Marital Status: 8. Spouse (including
Michael Gayoso, Jr. Office of the County Attorney TH
Michael Gayoso, Jr. Office of the County Attorney TH 11 Judicial District/Crawford County, Kansas DIVERSION PROGRAM -- DRIVING UNDER THE INFLUENCE Pursuant to K.S.A. 22-2906 et seq. the Crawford County
Nurse Practitioner Application for Professional Liability Insurance Additional Insured Basis*
Nurse Practitioner Application for Professional Liability Insurance Additional Insured Basis* IMPORTANT INSTRUCTIONS PLEASE READ CAREFULLY *Coverage on an Additional Insured Basis provides coverage only
Automobile Fleet Safety Manual. William Gallagher Associates Automobile Fleet Manual 1
Automobile Fleet Safety Manual William Gallagher Associates Automobile Fleet Manual 1 Table Of Contents Mission Statement 3 Company Rules and Regulations 4-5 Driver Qualifications 6 Drivers Licenses 6
DUI (Driving Under the Influence)
DUI (Driving Under the Influence) Driving Under the Influence (DUI) In Illinois, a person is considered to be driving under the influence when: The driver has an alcohol concentration on the breath of.08
BARTON COUNTY DUI DIVERSION PROGRAM GUIDELINES
BARTON COUNTY DUI DIVERSION PROGRAM GUIDELINES WHAT IS DIVERSION? The DUI diversion program offered and supervised by the Barton County Attorney enables certain people to complete a performance plan rather
TYPE OF OFFENSE(S) AND SECTION NUMBER(S) LIST OFFENSE(S), CASE NUMBER(S) AND DATE(S) CASE NUMBER(S) AND DATE(S)
SUPERIOR COURT OF CALIFORNIA Reserved for Clerk s File Stamp COUNTY: COUNTY OF EL DORADO PLAINTIFF: PEOPLE OF THE STATE OF CALIFORNIA DEFENDANT: DUI ADVISEMENT OF RIGHTS, WAIVER, AND PLEA FORM (Vehicle
CITY OF RIVERSIDE Application for Medical Transport Ambulance Franchise
CITY OF RIVERSIDE Application for Medical Transport Ambulance Franchise Subject to limited exceptions, Section 5.66.020 of the Riverside Municipal Code mandates that it shall be unlawful for any person,
Your Guide to Illinois Traffic Courts
Consumer Legal Guide Your Guide to Illinois Traffic Courts Presented by the Illinois Judges Association and the Illinois State Bar Association Illinois Judges Association Traffic courts hear more cases
DEFENDANT'S ARBITRATION DISCOVERY REQUESTS PERSONAL INJURY CLAIMS. IDENTITY OF PLAINTIFF(s) WITNESSES
,, Plaintiff vs. Defendant IN THE COURT OF COMMON PLEAS OF McKEAN COUNTY, PENNSYLVANIA CIVIL DIVISION NO. CD 20 DEFENDANT'S ARBITRATION DISCOVERY REQUESTS PERSONAL INJURY CLAIMS These discovery requests
WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured?
WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured? 3. How can I get help? 4. What information should I gather at the
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: : PEOPLE OF THE STATE OF CALIFORNIA v. DUI ADVISEMENT OF RIGHTS, WAIVER, AND PLEA FORM
MONROE COUNTY PUBLIC DEFENDER MONROE COUNTY COURTHOUSE 610 MONROE STREET, SUITE 21 STROUDSBURG, PENNSYLVANIA 18360
CHECKLIST FOR ALL FIRST OFFENSE DRIVING UNDER THE INFLUENCE CASES IMPORTANT: HIRE A LAWYER OR, IF YOU CANNOT AFFORD ONE, APPLY FOR A PUBLIC DEFENDER IMMEDIATELY. YOU MUST MEET INCOME GUIDELINES TO QUALIFY
PERSONAL INJURY INTAKE SHEET INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE?
PERSONAL INJURY INTAKE SHEET INITIAL CLIENT STATEMENT HAVE YOU SPOKEN TO ANOTHER ATTORNEY ABOUT THIS CASE? IF SO, PLEASE GIVE NAME OF ATTORNEY: DO YOU HAVE A SIGNED RELEASE BY THAT ATTORNEY? SOL: DATE
Leaders Life Insurance Accident Claim Filing Instructions
Leaders Life Insurance Accident Claim Filing Instructions Page One Filing Instructions: Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which
FURR & HENSHAW PERSONAL INJURY INTAKE SHEET. [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed
![FURR & HENSHAW PERSONAL INJURY INTAKE SHEET. [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed](/thumbs/27/9468527.jpg "FURR & HENSHAW PERSONAL INJURY INTAKE SHEET. [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed")
FURR & HENSHAW MYRTLE BEACH OFFICE: 1900 Oak Street, P.O. Box 2909, Myrtle Beach, SC 29578 (843) 626-7621 COLUMBIA OFFICE: 1534 Blanding Street, Columbia, SC 29201 (803) 252-4050 PLAINTIFF INFORMATION
California General Interrogatories (Wrongful Death) DEFINITIONS. 1. AREA means the name of the specific structure, building, building
California General Interrogatories (Wrongful Death) DEFINITIONS 1. AREA means the name of the specific structure, building, building number, floor of the building, ship compartment, process line, unit,
Allstate Indemnity Company Important Notice
Allstate Indemnity Company Important Notice Special Notice to Minnesota Auto Insureds The following surcharge information effective as of 8/2/2010 is provided to help you better understand your auto insurance
MIDDLETON SCHOOL DISTRICT #134 POLICY AND PROCEDURE MANUAL SECTION 800 Business Procedures. Conditions for Use of District Vehicles...
MIDDLETON SCHOOL DISTRICT #134 POLICY AND PROCEDURE MANUAL SECTION 800 Business Procedures Conditions for Use of District Vehicles...POLICY 808 OVERVIEW As a driver of a Middleton School District vehicle,
House Substitute for SENATE BILL No. 117
House Substitute for SENATE BILL No. 117 AN ACT regulating traffic; relating to transportation network companies, transportation network company services, regulation. Be it enacted by the Legislature of
PRETRIAL DUI DIVERSION INFORMATION SHEET
PRETRIAL DUI DIVERSION INFORMATION SHEET If you have been charged with Driving Under the Influence of Alcohol and/or Drugs or an alcohol related charge, you may be eligible for consideration for the City
IN THE COURT OF APPEALS OF INDIANA
Pursuant to Ind. Appellate Rule 65(D, this Memorandum Decision shall not be regarded as precedent or cited before any court except for the purpose of establishing the defense of res judicata, collateral
Dear Sir/Madam: Thank you for this opportunity to be of service, and please do not hesitate to contact our claims center if you have any questions.
Dear Sir/Madam: Kindly be advised that National Adjustment Bureau has been authorized by underwriters to adjudicate your claim. We look forward to resolving your claim in a prompt and equitable manner.
POLICY INVOLVING VEHICLE USE ON OFFICIAL COLLEGE BUSINESS AUTOMOBILES & OTHER MOTORIZED VEHICLES Last update: August 9, 2011
POLICY INVOLVING VEHICLE USE ON OFFICIAL COLLEGE BUSINESS AUTOMOBILES & OTHER MOTORIZED VEHICLES Last update: August 9, 2011 INTRODUCTION: Rollins College has many faculty, staff and students whose responsibilities
QUESTIONS AND ANSWERS ABOUT ILLINOIS AUTOMOBILE INSURANCE AND ACCIDENTS
QUESTIONS AND ANSWERS ABOUT ILLINOIS AUTOMOBILE INSURANCE AND ACCIDENTS What types of coverages are available? Generally, automobile insurance policies provide Bodily Injury and Property Damage Liability
CITY OF SALINA MUNICIPAL COURT DIVERSION INFORMATION AND APPLICATION
CITY OF SALINA MUNICIPAL COURT DIVERSION INFORMATION AND APPLICATION A diversion is a written agreement between the City Prosecutor and the defendant. During the diversion period, the prosecutor agrees
Accident Claim Filing Instructions
Accident Claim Filing Instructions Page One Filing Instructions Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which includes the date of service,
Application for New Louisiana Pharmacy Technician Candidate Registration
Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70809-1700 Telephone 225.925.6496 ~ Facsimile 225.925.6499 www.pharmacy.la.gov ~ E-mail: info@pharmacy.la.gov Application for New
TRAFFIC TICKET PLEA POLICY
TRAFFIC TICKET PLEA POLICY The following is the Chautauqua County District Attorney s plea policy for traffic tickets issued in Chautauqua County by the New York State Police. The procedure set forth below
COUNTY OWNED VEHICLE USAGE POLICY. Effective January 1, 2009
COUNTY OWNED VEHICLE USAGE POLICY Effective January 1, 2009 Ohio Revised Code 307.72 states that motor vehicles purchased or leased as provided by section 307.41 of the Revised Code shall be for the use
3. List all other names by which you have ever been known. Include marital and maiden names, nicknames and aliases.
[Interview Form - Personal Injury Case] 1. Personal and Family History Full name Present home address Present business address Home phone Business phone 2. of Injury or Accident Location of accident s
2014 PERSONAL HISTORY QUESTIONNAIRE
Department of Safety and Security 6054 South Drexel Avenue Chicago, Illinois 60637 2014 PERSONAL HISTORY QUESTIONNAIRE Applicant Name: Instructions Applicants for police officer positions at The University
INCIDENT INFORMATION SHEET. Driver or Passenger? (please circle)
INCIDENT INFORMATION SHEET CLIENT INFORMATION Date Client Name: Driver or Passenger? (please circle) Spouse s full name, if married: Home # Work # Cell # E-Mail at home E-Mail at work Date of Birth Social
General District Courts
General District Courts To Understand Your Visit to Court You Should Know: It is the courts wish that you know your rights and duties. We want every person who comes here to receive fair treatment in accordance
COMPANY VEHICLE POLICY
COMPANY VEHICLE POLICY Overview As an authorized driver of a company vehicle, you have been given certain privileges. You assume the duty of obeying all motor vehicle laws, maintaining the vehicle properly
Reference #: Date. Received: police report, Last Name. Middle Name. 2. Date of Birth: 4. Social Security. Zip Code. Apt # City. State. State.
Michigan Assigned Claims Plan c/o Michigan Automobile Insurance Placement Facility PO Box 532318 Livonia, MI 48153 2318 Phone: 734 464 8111 Internal Use Only Reference #: Date Received: Please note, you
GENERAL BACKGROUND INFORMATION
Internal Office Use Staff member initials for interview: Date of Incident : Statute of Limitations: Potential Defendants: CLIENT INTAKE FORM Please take the time to answer the questions below as accurately
Accident Claim Filing Instructions
Accident Claim Filing Instructions The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this authorization as We or Humana. Life, Specified
SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL. People v. Case No. Advisement of Rights, Waiver, and Plea Form
SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL People v. Case No. Advisement of Rights, Waiver, and Plea Form Vehicle Code 23152 Fill out this form if you wish to plead guilty or no contest to the charges
APPLICATION TO THE SACRAMENTO COUNTY BAR/ INDIGENT DEFENSE PANEL (IDP)
APPLICATION TO THE SACRAMENTO COUNTY BAR/ INDIGENT DEFENSE PANEL (IDP) 1. Read the enclosed summary of Program Description, Trial Requirements, Rules, Application, Agreement and Authorization and Release
The State of New Hampshire. James Hermonat Docket Nos. 97-S-524, 98-S-120-122, 98-S-169-180 ORDER
STRAFFORD, SS. SUPERIOR COURT The State of New Hampshire v. James Hermonat Docket Nos. 97-S-524, 98-S-120-122, 98-S-169-180 ORDER The defendant is charged with one count of Attempted Aggravated Felonious
PART III Discovery. Overview of the Discovery Process CHAPTER 8 KEY POINTS THE NATURE OF DISCOVERY. Information is obtainable by one or more discovery
PART III Discovery CHAPTER 8 Overview of the Discovery Process Generally, discovery is conducted freely by the parties without court intervention. Disclosure can be obtained through depositions, interrogatories,
STATE OF ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION DIVISION OF FINANCIAL INSTITUTIONS
RA 10 (DFI Page 1) STATE OF ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION DIVISION OF FINANCIAL INSTITUTIONS APPLICATION FOR REGISTRATION OF A TITLE AGENT All information must be typewritten.
PUBLIC DRUNKENNESS Section 5505 of the Pennsylvania Crimes Code (Title 18)
PUBLIC DRUNKENNESS Section 5505 of the Pennsylvania Crimes Code (Title 18) A person is guilty of a summary offense if he appears in any public place manifestly under the influence of alcohol to the degree
Teen Drivers & The Law:
Teen Drivers & The Law: What Every Parent in Washington State Needs To Know Parental Legal & Financial Liability for Auto Collisions Caused By Teen Drivers Mischelle Davis Director of Operations, Davis
YOUTH CENTER MENTORING PROGRAM Making a Difference through Adults in Action
PERSONAL INFORMATION Name: Date: Email: Phone Nos: MOBILE PHONE WORK PHONE Social Security No: (used for background check only) Date of Birth Gender: Male Female MO/DAY/YEAR Emergency: CONTACT NAME PHONE
Law & The Courts Resource Guide
Law & The Courts Resource Guide - what to do in case of an auto accident - your rights in traffic court - your rights if arrested table of contents What To Do In Case Of An Auto Accident...1 Your Rights
Chapter 813. Driving Under the Influence of Intoxicants 2013 EDITION. Title 59 Page 307 (2013 Edition)
Chapter 813 2013 EDITION Driving Under the Influence of Intoxicants GENERAL PROVISIONS 813.010 Driving under the influence of intoxicants; penalty 813.011 Felony driving under the influence of intoxicants;
Report and Recommendation In the Matter of Binh Quoc Doan, M.D. Page 2 II. Appearances A. On behalf of the State of Ohio: Jim Petro, Attorney General, by Rebecca J. Albers, Assistant Attorney General.
California General Interrogatories (Personal Injury) DEFINITIONS. 1. AREA means the name of the specific structure, building, building
California General Interrogatories (Personal Injury) DEFINITIONS 1. AREA means the name of the specific structure, building, building number, floor of the building, ship compartment, process line, unit,
RULES OF SUPREME COURT OF VIRGINIA PART THREE A CRIMINAL PRACTICE AND PROCEDURE APPENDIX
RULES OF SUPREME COURT OF VIRGINIA PART THREE A CRIMINAL PRACTICE AND PROCEDURE APPENDIX Form 6. Suggested Questions to Be Put by the Court to an Accused Who Has Pleaded Guilty (Rule 3A:8). Before accepting
DELAWARE COUNTY. Supersedes June 15, 1988, March 22, 1999
DELAWARE COUNTY Subject Self- Program Effective June 28, 2004 Supersedes June 15, 1988, March 22, 1999 This Sheet 1 Total 5 Purpose To provide a written document explaining the Self- Program, preferred
10/28/03 05:08 PM ET. Defendants Discove No.41
10/28/03 05:08 PM ET Defendants Discove No.41 [0/28/03 S TATE OF MICHIGAN N THE CIRCUIT COURT FOR THE COUNTY OF WAYNE IN RE: ALL ASBESTOS PERSONAL INJURY CASES Asbestos Master File I-Ion. Robert J. Colombo,
Clarion County ARD / DUI Program ARD APPLICATION CHECKLIST
Clarion County ARD / DUI Program ARD APPLICATION CHECKLIST The following items must be completed prior to entry, or during the ARD program. It is your responsibility to complete all of the following tasks
Employed, Subcontracting or Volunteer Dentist Community Clinic Program Application for Professional Liability Insurance Additional Insured Basis
Employed, Subcontracting or Volunteer Dentist Community Clinic Program Application for Professional Liability Insurance Additional Insured Basis Please type or print. Answer all questions. Please note
FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY
FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR TEACHING PERMIT Chapter 466.002, Florida Statutes Rule 64B5-7.005, Florida Administrative Code Applications will be accepted only if completed
WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? GET THE L E G A L F A C T S
T H E S TAT E B A R O F C A L I F O R N I A WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? GET THE L E G A L F A C T S O F L I F E What should I do if I have an 1 a u t o a c c i d e n t? If I have an auto