Form 208. Defendant’s Supplemental Interrogatories—

Defendant’s Supplemental Interrogatories—

Workers’ Compensation Benefits—No Intervening Plaintiff

No. CV-

: SUPERIOR COURT

(Plaintiff)

: JUDICIAL DISTRICT OF

VS.

: AT

(Defendant)

: (Date)

The undersigned, on behalf of the Defendant, hereby propounds the following interrogatories to be

answered by the Plaintiff,

, under oath, within sixty (60) days of the filing

hereof insofar as the disclosure sought will be of assistance in the defense of this action and can be

provided by the Plaintiff with substantially greater facility than could otherwise be obtained.

Definition: ‘‘You’’ shall mean the Plaintiff to whom these interrogatories are directed except that if

suit has been instituted by the representative of the estate of a decedent, ward, or incapable person,

‘‘you’’ shall also refer to the Plaintiff’s decedent, ward or incapable person unless the context of an

interrogatory clearly indicates otherwise.

In answering these interrogatories, the Plaintiff(s) is (are) required to provide all information within

their knowledge, possession or power. If an interrogatory has subparts, answer each subpart separately

and in full, and do not limit the answer to the interrogatory as a whole. If any interrogatories cannot

be answered in full, answer to the extent possible.

(1) State your full name, home address, and business address.

(2) State the workers’ compensation claim number and the date of injury of each workers’ compensation claim that you have filed as a result of the incident/occurrence alleged in the Complaint.

(3) State the total amount paid on your behalf on each of the claims filed as a result of the incident/

occurrence alleged in the Complaint and referred to in Interrogatory #2, and if known, specify the

amount of medical benefits, loss of income benefits, and specific award benefits, and if unknown,

provide an authorization for the same.

result of the incident/occurrence alleged in the Complaint.

(3) State the total amount paid on your behalf on each of the claims filed as a result of the incident/

occurrence alleged in the Complaint and referred to in Interrogatory #2, and if known, specify the

amount of medical benefits, loss of income benefits, and specific award benefits, and if unknown,

provide an authorization for the same.

(4) Identify any First Report of Injury, Notice of Claim for Compensation, Notice of Intention to Reduce

or Discontinue Benefits, Notice to Administrative Law Judge and Employee of Intention to Contest

Employee’s Right to Compensation Benefits, and any reports of medical exams requested by the

administrative law judge, respondent and/or employer arising out of the incident/occurrence alleged in

the Complaint.

(5) Identify any voluntary agreements, approved stipulations to date, approved full and final stipulations and findings and awards, and findings and denials arising out of the incident/occurrence alleged

in the Complaint and which formed the basis for your answer to Interrogatory #3.

(6) Which of your claims arising out of the incident/occurrence alleged in the Complaint and referenced

in your answer to Interrogatory #2 are still open?

COMMENT:

These supplemental interrogatories are specifically directed at eliciting information about any workers’ compensation claims,

benefits and agreements. Unless the compensation carrier is a party to the action, it can be difficult to obtain this information.

Often the Plaintiff’s lawyers do not represent the client in the workers’ compensation case, and although this information is

available in the workers’ compensation file, providing these records to lawyers not involved in the compensation case could be