CLAIM FORM AND BODILY INJURY/WRONGFUL DEATH CLAIM QUESTIONNAIRE

Transcription

1 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 to any of the information requested, please attach a separate sheet. 1. If an action is pending, set forth (a) the full and complete title of the action; (b) the court in which such action is pending; and (c) the index and/or case number of the action. 2. Set forth the claimant s or claimants full name, present address and date of birth. 3. Describe in detail your version of the accident or occurrences setting forth the date, location, time and weather.

2 4. Describe in detail the factual and legal basis on which you assert that each of the defendants or any other person you claim is liable, including any of the Debtors or their employees, servants, agents or representatives, are liable for the damages allegedly sustained by you. 5. Detailed description of nature, extent and duration of any and all injuries. 6. Detailed description of injury or condition claimed to be permanent together with all present complaints. discharge. 7. If confined to a hospital, state its name and address, and dates of admission and 8. If any diagnostic tests were performed, state the type of test performed, name and address of place where performed, date each test was performed and what each test disclosed. Attach a copy of the test results. 9. If treated by any health care provider, state the name and present address of each health care provider, the dates and places where treatments were received and the date of the last treatment. Attach true copies of all written reports provided to you by such health care provider. 10. If still being treated, the name and address of each doctor or health care provider rendering treatment, where and how often treatment is received and the nature of the treatment. 11. If a previous injury, disease, illness or condition is claimed to have been accelerated or exacerbated, specify in detail the nature of each and the name and present address 2

3 of each health care provider, if any, who ever provided treatment for the condition. Attach true copies of all medical records, including, x-rays, test results and MRI s, relating to the prior injury, disease, illness or condition in your possession. 12. If employed at the time of the accident, state: (a) name and address of employer; (b) position held and nature of work performed; (c) average weekly wages for past year; (d) period of time lost from employment, giving dates; and (e) amount of wages lost, if any. 13. If there has been a return to employment or occupation, state: (a) name and address of present employer; (b) position held and nature of work performed; and (c) present weekly wages, earning, income or profit. 14. If other loss of income, profit or earnings is claimed: (a) state total amount of the loss; (b) give a complete detailed computation of the loss; and (c) state the nature and source of the loss of income, profit and earnings, and the dates of the deprivation. Attach true copies of all tax returns, wage statements, W-2 forms, W-4 forms and 1099 forms since the earlier of two years or the date of the alleged accident. 15. Itemize in complete detail any and all moneys expended or expenses incurred for hospitals, doctors, nurses, diagnostic tests or health care providers, x-rays, medicines, care and appliances and state the name and address of each payee and the amount paid and owed each payee. Attach true copies of all medical bills and invoices. 16. Itemize any and all other losses or expenses incurred not otherwise set forth. 3

4 17. State the names and addresses of all persons who have knowledge of any facts relating to the case. 18. If you claim that the debtor or any agent of the debtor made any admissions as to the subject matter of this lawsuit, stated: (a) the date made; (b) the name of the person by whom made; (c) the name and address of the person to whom made; (d) where made; (e) the name and address of each person present at the time the admission was made; (f) the contents of the admission; and (g) if in writing, attach a copy. 19. If you or your representative and the debtor have had any oral communication concerning the subject matter of this lawsuit, state: (a) the date of the communication; (b) the name and address of each participant; (c) the name and address of each person present at the time of such communication; (d) where such communication took place; and (e) a summary of what was said by each party participating in the communication. 20. If you have obtained a statement from a person not a party to this action, state: (a) the name and present address of the person who gave the statement; (b) whether the statement was oral or in writing and if in writing, attach a copy; (c) the date the statement was obtained; (d) if such statement was oral, whether a recording was made, and if so, the nature of the recording and the name and present address of the person who has custody of it; (e) if the statement was written, whether it was signed by the person making it; (f) the name and address of the person who obtained the statement; and (g) if the statement was oral, a detailed summary of its contents. 4

5 21. If you claim that the violation of any statute, rule, regulation or ordinance is a factor in this litigation, state the exact title and section. 22. State the names and addresses of any and all proposed expert witnesses and attach true copies of all written reports provided to you by any such proposed expert witnesses. With respect to all expert witnesses, including treating physicians, who are expected to testify at trial and with respect to any person who has conducted an examination, who may testify, state each witness s name, address and area of expertise and attach a true copy of all written reports provided to you. If a report is not written, supply a summary of any oral report provided to you. State the subject matter on which your experts are expected to testify. State the substance of the facts and opinions to which your experts are expected to testify and a summary of the grounds for each opinion. 23. If this is a wrongful death claim, set forth (a) your relationship with the decedent; (b) the date and time of death of the decedent; and (c) heirs to the decedent; and attach true and complete copies of (a) any autopsy reports and (b) letters of administration or testamentary or other equivalent document from a court of competent jurisdiction. 24. Do you have any insurance coverage and/or PIP benefits under an applicable policy or policies of automobile insurance? As to each such policy provide the name and address of the insurance carrier, policy number, the named insured and attach a copy of the declaration sheet. 5

6 25. a. Total Damages Claimed: b. Past Medical Costs: c. Future Medical Costs: d. Future Lost Wages: e. Pain and Suffering: f. Other Specify: g. Other Specify: h. Other Specify: i. Other Specify: j. Other Specify: k. Total (Add lines b-k) $ If a. is not equal to k., explain the reason for the discrepancy. 26. Provide any other information you believe may be helpful or relevant in assessing your claim. By executing this Claim Form and Bodily Injury/Wrongful Death Claim Questionnaire, the claimant/claimants acknowledge that such claimant/claimants (a) agree not to take any action of any kind to enforce any judgment against the Debtors and (b) to waive any claim or right to be paid from the Debtors or their estates. 6

7 TheThe claimant/claimants andthe claimant/claimants and their attorneysthe claimant/claimants a informationinformation contained in this Claim Form and Bodily Injury/Wrongful Deatinformatio Questionnaire, including any attachment hereto, is true, correct and complete. Please have the signatures at the end of this document witnessed by a notary public. Claimant s Signature Attorney s Signature Sworn to before me this day of Notary Public 7

8 CLAIM FORM AND PROPERTY DAMAGE CLAIM QUESTIONNAIRE Claimant s Name: Attorney s Name: Address: City/State: Firm: Address: Phone: City/State: Phone: * Should you require additional space in responding to any of the information requested, please attach a separate sheet. 1. If an action is pending, set forth (a) the full and complete title of the action; (b) the court in which such action is pending; and (c) the index and/or case number of the action. 2. Is the claimant the sole owner of the property damaged in the alleged accident? 3. Describe in detail your version of the accident or occurrences setting forth the date, location, time and weather.

9 4. Describe in detail the factual and legal basis on which you assert that each of the defendants or any other person you claim is liable, including any of the Debtors or their employees, servants, agents or representatives, are liable for the damages allegedly sustained by you. 5. State the name and address of the person, firm or corporation from whom the claimant purchased the property and the date of purchase. 6. Was the property new or used at the time of the purchase? 7. State amount paid by claimant for the said propert y. 8. State whether the property has been repaired since the accident. 9. If so, give name and address of person, firm, or corporation making the repairs. 10. If so, state specifically the part or parts of the property alleged to have been damaged in the accident and furnish a copy of the repair bill. 11. State date upon which claimant authorized the repair of the property. 12. State date on which repairs were completed. 13. State the market value of the property immediately before the accident. the accident. 14. State the market value of the property in its damaged condition immediately after 2

10 15. State the market value of the property in its repaired condition. 16. Was the property used in connection with claimant s business and, if so, state whether claimant was obliged to hire other property for use in connection with that business, giving the name and address of person, firm or corporation from whom claimant hired replacement property, the dates during which it was hired and the amount paid for its hiring. 17. If no repairs have been made, but an estimate of repairs has been obtained, attach a copy of the estimate to this form, stating further the name and address of the person, firm or corporation who made the estimate. 18. Has the claimant sold or otherwise disposed of the propert y. 19. If so, give the name and address of the person, firm or corporation to whom he property was transferred, the date of the transfer, and the amount of consideration paid to the claimant therefore. 20. If it is alleged that the claimant incurred any other expenses or losses as a result of the alleged damage to the property, set forth these additional losses in detail, giving an itemized statement. 21. State the names and addresses of all persons who have knowledge of any relevant facts relating to the case. 22. State the names and addresses of any and all proposed expert witnesses and annex true copies of all written reports provided to you by any such proposed expert witnesses. 3

11 23. a. Amount Claimed: $ b. Cost of Repairs: $ c. Cost of Replacement: $ d. Diminution in Value: $ e. Cost of Rental or $ f. Leasing of Replacement: $ g. Lost Profits: $ h. Total (Add lines b-g) $ 24. If amount in line h. differs from amount on line a, explain the reason for the difference. your claim. 25. Provide any other information you believe may be helpful or relevant in assessing ByBy executing this Claim Form and Bodily InjurBy executing this Claim Form and Bodily Injury/WroB thethe claimant/claimants acknowledge that such claimant/claimants (a) agree not to take any actionaction of any kind to enforce any judgment against the Debtors and (b) to waive any claim or right to be paid from the Debtors or their estates. The claimant/claimants and their attorneys declare, under penalty for perjury, that the information contained in this Claim Form and Bodily Injury/Wrongful Death Claim 4

12 Questionnaire, including any attachment hereto, is true, correct and complete. Please have the signatures at the end of this document witnessed by a notary public. Claimant s Signature Attorney s Signature Sworn to before me this day of Notary Public E:\ \bkcy\metroclaims form.wpd 5