Your Name*
First
Middle
Last
Suffix
Today's Date* Date of the Car Crash* Treating doctors and health care after the crash. Question 1 List the name and business addresses of each physician who has treated or examined you, and each medical facility where you have received any treatment or examination for the injuries for which you seek damages in this case; and state as to each the date of treatment or examination and the injury or condition for which you were examined or treated.
Question 1 List All Medical Providers that Treated you for this Crash This one is very important to get correct. List every doctor, hospital, clinic, ambulance driver, fireman, X-Ray, MRI, and any labs that may have done any work, or looked or treated you in any way. I have listed the doctors we know about because you are treating with them for this accident, But, if we are missing any doctors, then we obviously don't know about them and need you to list them here. So please list each and every health care professional that you have seen, no matter how irrelevant it may seem
Check off every one of these that saw you for this accident: Which Fire Rescue was involved?*
Which Ambulance gave you any assistance?*
Which Hospital were you admitted into?*
Which Walk In Clinics did you visit?*
What are the names of the Chiropractic offices you have been a patient in?*
Did you have any out patient X-Rays?*
Did you ever go to any place outside of the doctors office just to get X-rays? If so, tell us where you went.
Did you have any MRI's done?*
Where did you get your MRI's?
What other tests or studies were done other than X-ray or MRI? Where did you get them done?*
What other studies were done and where did you get them done?
Primary Care Physician name and location*
If you saw your Primary Care Physician, we list this doctor in your answers. Please provide the name and location of your PCP.
Neurologist name and location*
Psychiatrist name and location*
Orthopedic Surgeon name and location*
Neuro Surgeon name and location*
Physical Therapy name and location*
Acupuncture name and location*
Pharmacies that I used; names and locations*
Other medical or health care providers I have seen after the collision include:*
Please help us list every medical professional you have seen. Nothing is too minor. Please tell us everything.
Medical care and treatments BEFORE the Car Crash Question 2 List the names and business addresses of all other physicians, medical facilities or other health care providers by whom or at which you have been examined or treated in the past ten years; and state as to each the dates of examination or treatment and the condition or injury for which you were examined or treated.
Question 2 List EVERY health care provider you have seen in the past 10 years before the car crash This one requires you to list every health care professional you can possibly think of that you have seen in the PAST 10 YEARS. If you forget or leave out a doctor, hospital, chiropractor, walk in clinic, they will say that you were hiding this information from them and they will try to make you look like a liar. They will also suggest that your injuries you have today really came from something before this accident, not from this one. But don't worry about that because the law in Florida says that if you have pre-existing injuries or conditions and they are made worse by this crash, you are entitled to more money not less, because it is easier to hurt you, and the aggravation of pre-existing injuries will be more serious.
In the past 10 years I have seen the following:* 10 years prior Primary Care Doctors information:*
Name, Address, and generally what they saw you for.
10 years prior Emergency Room visit information:*
Name, Address, and generally why they saw you.
10 years prior Physical Therapy sessions:*
Name, Address, and generally what types of physical therapy you have had.
10 years prior Chiropractic doctors and any treatments:*
Name, Address, of any and all chiropractors you have seen for the 10 years before this accident.
10 years prior Dentists:*
Name, Address, of any and all Dentist you have seen for the 10 years before this accident.
10 years prior Hospitals:*
Name, Address, of any and all Hospital you have seen for the 10 years before this accident.
10 years prior Walk In Clinics:*
Name, Address, of any and all Walk In Clinics you have to in the 10 years before this accident.
10 years prior Acupuncture treatments:*
Name, Address, of any and all Acupuncture treatments you have to in the 10 years before this accident.
10 years prior Psychologist visits for any reason.*
Name, Address, of any and all Psychologists visits you have to in the 10 years before this accident.
10 years prior meetings with Mental Health Care professionals.*
Name, Address, of any and all Mental Health Care professionals you have seen in the 10 years before this accident.
10 years prior meetings with any Podiatrists - foot doctor:*
Name, Address, of any and all Podiatrists you have seen in the 10 years before this accident.
10 years prior meetings with any Nutritionalist - Diet Counseling:*
Name, Address, of any and all Nutritionist(s) you have seen in the 10 years before this accident.
10 years prior pharmacies that you have used, no matter where.*
Name, Address, of any and all Pharmacies you have used in the 10 years before this accident.
10 years prior OBGYN doctors*
Name, Address, of any and all OBGYN you have used in the 10 years before this accident.
10 years any Plastic Surgeons*
Name, Address, of any and all Plastic Surgeons you have used in the 10 years before this accident.
10 years any Surgery Centers*
Name, Address, of any and all Surgery Centers, for any out patient procedures, such as colonoscopy, endoscopy, cataract surgery, etc.
10 years any Opthalmologist - Eye Doctors*
Name, Address, of any and all Ophthalmologists.
10 years any Optometrists*
Name, Address, of any and all Optometrists.
10 years any other types of medical health care professionals.*
Name, Address, of any and all other health care professionals that have seen you for any reason over the 10 years before this accident.
If you selected None, for no prior medical care, please explain how and why?*
If you have not seen any medical professionals for any care in the 10 years before this accident, please help us understand your explanation for this.
Pre-Existing injuries and or health conditions Question 3: Were you suffering from physical infirmity, disability, or sickness at the time of the incident described in the complaint? If so, what was the nature of the infirmity, disability, or sickness?
Question 3: List any and all Pre-Existing Conditions you have before the crash that may have been aggravated in any way. The answer to this questions is usually YES! Everyone has had headaches, and colds in their life, but were you suffering from a bad back, or sore neck, or anything else before the accident occurred? Were you on medication for any condition, like high blood pressure? The fact that you have had an injury, illness or disease actually helps your case. We just have to make sure we tell them about it, so it does not look like you are trying to hide something. The law in Florida basically says that people with pre-existing conditions are entitled to more money because they are easier to hurt and harder to fix. So my suggestion is that you brag about any pre-existing injuries or conditions (no matter how old) rather than try to minimize them.
At the time of the crash did you have any medical things going on?* My prior injuries and conditions that I suffered from before this crash include:*
Please list any and all health conditions that may have been affected by this crash. Things like high blood pressure, diabetes, arthritis, rheumatoid arthritis, depression may be worsened by a car crash. List them all, it is better to say too much than too little here.
The medications I was taking before this crash include:*
Please list any medications you were taking on a some what frequent basis, like baby aspirin, cholesterol medications, blood pressure medications, even daily vitamins.
I have prior injuries to my body before this crash and they were:*
List any and all injuries where you sought medical attention.
Here is a list of the surgeries I had before this car crash*
List each and every surgery you have had before this crash.
Psychologists or Mental Health Care Professionals I saw before this crash include:*
List each and every psychologist or mental health care specialist you have seen. Grief counseling, depression, job anxiety, anything. We may not need it, but let me know about this.
Describe how your pre-existing conditions have worsened by this crash.*
Please describe the additional problems you have now that were caused by the crash.
If you have never had any prior medical care or treatment before this crash, please help us understand how and why you are so fortunate.*
If you have NEVER had any treatment, be prepared to answer the question "How is it that you have never seen a doctor for anything before this crash?
Employment information Question 4 List the names, business addresses, dates of employment and rates of pay regarding all employers, including self-employment, for whom you have worked in the past ten years.
Question 4: List all prior employment and rates of pay for the past 10 years. You want to list every employer, good ones and bad ones. This is important to the defense for two reasons, the first is to challenge your lost wages or earnings and second to look for any health insurance you may have had through your work or any workers compensation claims you have made. If you forget or leave out an employer, the Insurance Defense lawyer may suggest you are being dishonest. Please list all of your prior employment.
My prior employment is:* List the employers you have had, their addresses, your rate of pay, and approximate dates of employment with each job.*
Describe your self employment, what do you do, how much have you been paid, and what do your taxes reflect your income to be?*
I have not worked because:* Tell us anything else about your prior employment and earnings that may be useful in your case.
Loss Of Future Earnings Caused By Car Crash Injuries Question 5 Do you contend that you have lost any income, benefits, or earning capacity in the past or future as a result of the incident described in the complaint? If so, state the nature of the income, benefits, or earning capacity, and the amount and method that you used in computing the amount
Question 5: Your Lost Wages and benefits in the past and any loss of future income. This is basically 3 questions in one. First, Do you have lost wages caused by the car accident? Second, have you lost any employment benefits caused by the car accident? And Third will you have lost wages in the future caused by the car accident? 1) Past Lost Wages: We want to calculate every penny of lost wages that you suffered because of this car accident. 2) Lost Benefits are listed below and select any losses that apply to your particular situation. 3) Future Earnings addresses questions like, will you get raises like you used to get since you were hurt? We want to tell them how will lose money because of your injury and how you calculated the figure. Don't worry too much about the calculations, just tell them what you lost, and what you think you will lose in the future and we may have an accountant or an economist calculate this for you.
5-A) What Past Wages have you lost because of this car accident?* This is asking about what wages or earnings you have lost since the accident up to the date of answering this question.
The reason I have NO Past lost wages is:* My past lost wages were paid in the following manner:* Explain how you calculate your past lost wages caused by this car crash.*
5-B) How I feel about my future ability to work after this crash: Pick the answer that best describes any loss of work you may have due to your injuries from this crash. Then in the paragraphs below, give us more details to support how you feel.
My ability to earn money in the future has been reduced by:* Select any reason below that you feel describes your loss of earing capacity in the future.* Describe how you have lost future income or earning capacity becasue of this crash.
5-C) Check off any "Benefits" from working you have lost due to this crash Some people when they are hurt, or miss work, they lose benefits that they otherwise would earn or be entitled to if they were not injured. Please select any benefits you have lost as a result of this incident.
Question 6 List all former names and when you were known by those names. State all addresses where you have lived for the past ten years, the dates you lived at each address, your social security number, your date of birth, and if you are or have ever been married, the name of your spouse or spouses.
Question 6: Addresses of where you have lived over the past 10 years. They want every address, every name, and all other piece of information about you so that they can check on your history and lifestyle over the past 10 years.
My Former names are:* Have you ever been known by any other names, such as maiden names, or legally changed your name for any reason, or ever used someone else's name. They don't want nick names such as Mike for Michael.
What other names have you been known as?*
Please provide the other names you have been know as and the circumstances of why you were known by that name and now are known by another name.
My marital status is:* have you ever been married?
My spouse's name is
First
Middle
Last
I have been married ___ times.*
My ex-spouse's name is:*
First
Last
My present address is:*
How long have you lived at your present address? My prior address where I lived before was:
Provide the address where you lived before.
I lived at this second address from this date to that date*
Fill in the approximate months and years you lived at this second address.
Do the two addresses you listed above when combined, cover 10 years or more of your residence addresses?* Question 7 Do you wear glasses, contact lenses, or hearing aids? If so, who prescribed them, when were they prescribed, when were your eyes or ears last examined, and what is the name and address of the examiner?
Question 7: Do you wear glasses? In other words, was the accident your fault because you did not see very well and you were not wearing your prescription glasses, or did you fail to hear something? Can they pin any fault on you?
As far as glasses and hearing aids:* What is the name and address of who last examined your eyes and approximately when was the examination?*
What is the name, address and date when you last had a hearing examination or hearing aids adjusted?*
Question 8 Have you ever been convicted of a crime, other than any juvenile adjudication, which under the law under which you were convicted was punishable by death or imprisonment in excess of 1 year, or that involved dishonesty or a false statement regardless of the punishment? If so, state as to each conviction the specific crime and the date and place of conviction.
Question 8: List any and all criminal convictions. We want to accurately list any and all criminal convictions you may have as an adult. If you have any convictions and we tell the truth about them, this will prevent the insurance defense lawyer from telling the jury what your convictions were for. But if you get this wrong, the defense lawyer may get to talk all about your prior criminal convictions in great detail. Therefore, If you have any doubts about whether something resulted in a conviction, we can order a criminal history report from each state where you suspect a conviction may have been given to you. Also, if we know about them, we can usually get the judge to order the defense not to talk about any that are over 10 years old. But we have to know about this to protect you from this damaging testimony that can only be used against you if you don't answer this question correctly.
Criminal Convictions:* If you are not certain of a conviction, please let us know. What we will do with your answer is order a copy of your records and confirm if you were ever convicted. Please help us find this out accurately. It will save a lot of problems later if we know now of any and all convictions.
The Charge, year, State and County of any possible convictions are:*
Describe any and all possible criminal conviction you have had. The more information you give us the easier it will be to make sure we answer this question accurately.
Question 9 Did you consume any alcoholic beverages or take any drugs or medication within twelve hours before the time of the incident described in the complaint? If so, state the type and amount of alcoholic beverages, drugs or medication which were consumed and when and where you consumed them.
Question 9: Were you drinking or taking drugs or medications? Were you drinking or did you take any medication before the accident? They want to suggest that you were intoxicated and therefore the accident is at least partially your fault.
My consumption of alcohol, drugs and medication within 12 hours of the crash was:* Describe the alcohol you consumed before the accident. What did you consume, when, and how much.*
List the medications you were taking at the time of the crash*
Describe the illicit drugs you consumed before the accident. What did you consume, when, and how much.*
Question 10 Describe in detail how the incident described in the complaint happened, including all actions taken by you to prevent the incident.
Question 10: What did you do to avoid the crash? What did you do to avoid or reduce the severity of this accident? We want to make a list of everything you did right before the accident. The insurance company lawyer wants to place some blame on you for this accident.
Check all that apply to your car crash* Question 11 Describe in detail each act or omission on the part of any party to this lawsuit that you contend constituted negligence that was a contributing legal cause of the incident in question.
Question 11: What did the other people do wrong that led to or caused the crash? What did the other people do wrong that caused this accident? Did anyone do anything to make it worse? Did they drive too fast? Did they turn when it was not safe to do so? Were they drinking alcohol or appear to be on drugs? The more clearly we can explain why it is the other driver's fault the easier it will be to win this part of your case, that is who is at fault.
Check all that apply to your car crash* What else did the at fault driver do that caused or contributed to the crash?
Please add anything else that may apply that would cause a jury to find that the other driver was at fault for the colission.
Question 12 Were you charged with any violation of law (including any regulations or ordinances) arising out of the incident described in the complaint? If so, what was the nature of the charge; what plea or answer, if any, did you enter to the charge; what court or agency heard the charge; was any written report prepared by anyone regarding this charge, and, if so, what is the name and address of the person or entity that prepared the report; do you have a copy of the report; and was the testimony at any trial, hearing, or other proceeding on the charge recorded in any manner, and, if so, what is the name and address of the person who recorded the testimony?
Question 12: Did you get a ticket? Did you get a ticket? If so, tell them what happened in court. The insurance company wants to know if they can use any traffic citation you got against you at trial.
Did you get a traffic ticket?* I was given a ticket(s) for the following:*
After the ticket I:* Question 13 Describe each injury for which you are claiming damages in this case, specifying the part of your body that was injured, the nature of the injury, and, as to any injuries you contend are permanent, the effects on you that you claim are permanent.
Question 13: What still hurts that you are seeking damages for? What still hurts? Cuts, scars, headaches, neck pain, back pain, can't sleep, numbness on a constant basis anywhere? This is important to list in writing all of the problems you have today. The defense has the right to know what you will tell a jury about your injuries. If you don't say much about them, then you can't say more at trial. Also, if you complain about every little tiny thing, then you may turn off a jury and sound like a complainer. I suggest you answer this question fully, and if you are not sure whether to include something or not, please include it so that we can talk about it later and possibly edit your answer to most help your case.
Check all injuries that you have from the crash, or were aggravated by the crash.* Please describe any other pain or injuries you attribute to this accident.
Please explain any other physical or mental symptoms or problems you relate to this crash.
Question 14 List each item of expense or damage, other than loss of income or earning capacity, that you claim to have incurred as a result of the incident described in the complaint, giving for each item the date incurred, the name and business address to whom each was paid or is owed, and the goods or services for which each was incurred.
Question 14: What Property Damages are you claiming that have not been resolved yet? Are you claiming any loss for the damages to your vehicle, loss of use, or depreciation in its value? Also, list any extra expenses you have from this incident, including: cleaning services, lawn maintenance, damages to your car, broken eye glasses, torn clothing, damaged things in your car, prescription drugs, bandages, aspirin, heating pads, crutches, etc. anything you have spent a penny on, that is related to your accident.
Check each item of expense or damage that you relate to this crash.* List every expense or debt you incurred that was caused by the car crash.
What prescription medications have you purchased, where did you get them and what is the cost?*
Please give us details regarding how much you have paid or owe for medications related to this car crash. The more detail we can provide to the defense, the easier it will be to get this reimbursed. Also, please send us any receipts you might have if you have not given them to us already.
What over the counter medications have you purchased, where did you get them and what is the cost?*
Please give us details regarding how much you have paid or over the counter medications related to this car crash. The more detail we can provide to the defense, the easier it will be to get this reimbursed. Also, please send us any receipts or bills you may not have sent us already.
Lets calculate the number of miles you have driven your car to go to and from your doctors appointments. How many visits, and how many miles did you drive?*
If you can tell us how many miles it is round trip to each of your doctors we can calculate the mileage, with the times you have been to each of them.
How much have you paid for cleaning services, and who did you pay?*
How much have you paid for lawn services, and who did you pay?*
What Vehicle Expenses do you claim that have not been paid?* If your Property Damage claim has been resolved, say None. If not, list the losses you still have not been paid for.
Depreciation of the value of your car caused by the crash.*
If your car was damaged and you believe it has lost value because it is damaged, you can make a claim for this depreciation against a bad driver, but not your own UM insurance company. How much value do you believe you lost in your vehicle as a result of it being damaged in a crash?
What unreimbursed rental car expenses do you have?*
Please tell us the amount of unreimbursed rental car expenses you have, and who you paid for this.
What unreimbursed towing expenses do you have, how much and who did you pay?*
Please tell us the amount of unreimbursed towing you have, and who you paid for this.
What other expenses do you have that you feel are caused by this car crash, please tell us what the expense is for and the amounts you paid and who you paid them to.*
Please tell us the amount of unreimbursed towing you have, and who you paid for this.
Question 15 Has anything been paid or is anything payable from any third party for the damages listed in your answers to these interrogatories? If so, state the amounts paid or payable, the name and business address of the person or entity who paid or owes said amounts, and which of those third parties have or claim a right of subrogation.
Question 15: Did your PIP or Health Insurance pay any bills? Did your PIP auto policy, health insurance, medicaid, medicare, HRS, or social security pay anything for you?
Did any third party pay any of your expenses?* If you select Yes, we will ask you who may have paid anything. Select No, if you don't have any PIP insurance, Health Insurance, Medicare, Medicaid, Social Security or any other payor.
Check all that may have paid anything My Health Insurance Company name is: My Group Number is: and my Policy Start Date was:
Please provide the Name of your Health Insurance Company, the Group number, and the date your Health Insurance Policy went into effect
The VA may have paid some bills, Tell us Which VA to order your file
Please provide the VA location where you have been treated in the past 10 years.
How do we contact Medicare? Name of the carrier, group number and your policy number and the effective date your insurance started.*
Please give us the name of all Medicare policies, supplement policies, we need the name of the insurance company, the group number, your policy number and the effective date when the coverage started.
How do we contact Medicaid? Name of the carrier, group number and your policy number and the effective date your insurance started.*
Please give us the name of all Medicaid policies, supplement policies, we need the name of the insurance company, the group number, your policy number and the effective date when the coverage started.
How do we contact Wellcare? Name of the carrier, group number and your policy number and the effective date your insurance started.*
Please give us the name of all Wellcare policies even if it is known by some other name, provide any supplement policies you may have, we need the name of the insurance company, the group number, your policy number and the effective date when the coverage started.
What Other types of insurance do you have that might cover payment of any medical bills, or disability?*
We need to know about any other types of insurance you might have, whether governmental paid, private insurance, things like disability insurance, AFLAC, or anything else that could potentially provide any payment for your bills or wages.
Question 16 List the names and addresses of all persons who are believed or known by you, your agents or attorneys to have any knowledge concerning any of the issues in this lawsuit; and specify the subject matter about which the witness has knowledge.
Question 16: Who is a Fact Witness regarding the Crash or your injuries? Usually, you, your family, all the witnesses to the accident, all of your doctors, any police officers, ambulance drivers, your employers, co-workers, and friends who know how bad you were hurt.
Select all that may apply.* Name of eye witness
First
Last
If you have the name of the eye witness, please let us know who they are so that we may contact them.
Name of co-worker who might help us with your case
First
Last
If you have the name of a co-worker that might be willing to help us with your case, please let us know who they are so that we may contact them.
Any other witness information you have to help prove your case
If you know of anyone else that we might want to contact and see if they are willing to assist us with your case, please add their name, contact information and what they may know to help us with your case.
Question 17 Have you heard or do you know about any statement or remark made by or on behalf of any party to this lawsuit, other than yourself, concerning any issue in this lawsuit? If so, state the name and address of each person who made the statement or statements, the name and address of each person who heard it, and the date, time, place and substance of each statement.
Question 17: What Admissions did the at fault party make that will help prove they were at fault for this crash? Did any driver or and defendant say anything about what happened? Did they make any admissions that we can tell the jury about? If so, we have to let the defense know now about any admissions or statements their client made that helps your case and hurts the defendants case.
The defendant driver said:* What else, if anything, was said at or after the crash about this?
If you heard the bad driver say anything that might be an admission by them regarding liability please let us know. Things like drinking, taking drugs, admitting to speeding, who owned the car, that they were working. Anything you heard might be helpful
Question 18 State the name and address of every person known to you, your agents, or your attorneys, who has knowledge about, or possession, custody, or control of, any model, plat, map, drawing, motion picture, videotape, or photograph pertaining to any fact or issue involved in this controversy; and describe as to each, what item such person has, the name and address of the person who took or prepared it, and the date it was taken or prepared.
Question 18: Who has any evidence or photographs of what happened? Usually, just the police, their insurance company, your insurance company, the defendant is all that I would know who may have photos, etc.
Select all that apply* Please upload any photographs you have to help your case. Please send us any photographs that you have that may help your case in any way.
Question 19 Do you intend to call any expert witnesses at the trial of this case? If so, state as to each such witness the name, and business address of the witness, the witness's qualifications as an expert, the subject matter upon which the witness is expected to testify, the substance of the facts and opinions to which the witness is expected to testify, and a summary of the grounds for each opinion.
Question 19: Who might be your expert witnesses to prove your case? Usually you will not know what “Experts” you will use beyond your treating doctors.
Select any that you think apply* Question 20 Have you made an agreement with anyone that would limit that party's liability to anyone for any of the damages sued upon in this case? If so, state the terms of the agreement and the parties to it.
Question 20: Confirm that you have not made any side agreements with any defendants to limit your recovery. Usually you have not made any such agreements.
Settlement agreements are:* Question 21 Please state if you have ever been a party, either plaintiff or defendant, in a lawsuit other than this one, and if so, state whether you were a plaintiff or defendant, the nature of the action, and the date and court in which such suit was filed.
Question 21: What prior Lawsuits have you been involved in? They want to know about any lawsuits you have ever been involved in, divorce included.
Check all that apply.* Tell us about any prior lawsuits. The type of case, the date the case was filed, the State and County where the matter was filed.*
Question 22 Have you been in any other type of accidents before such as other car accidents, slip and falls, boating accidents, sporting injuries?
Question 22: List all prior accidents of any type where you saw any type of health care provider. They just want to know what other accidents you have possibly been in where you sought ANY medical treatment, no matter how minor.
Prior accidents that I have been involved in where I had some injury include:* The insurance defense lawyer will likely have in their data base a list of every time you have been to a doctor. If you can remember any prior accidents, it is going to make your case go smoother. If you forget one or two, or three accidents where you sought medical treatment, they will suggest that you are hiding these prior accidents. So, do your best to tell us and your doctors you are treating with now about any prior accidents involving ANY injury.
Describe the prior accidents. When they happened, what type of accident, Where you sought treatment and describe the injuries you received, and when your treatment stopped for those injuries.*
Question 23 List your prior automobile and health insurance companies you have had over the past 10 years.
Question 23: List your prior insurance companies. They just want to know where else you have had insurance so that they can subpoena their records about you and find any claims you have made, or lists of any doctors or treatment you may have obtained in the past 10 years.
My Automobile Insurance Companies for the past 10 years were:*
My Health Insurance Companies for the past 10 years were:*
Question 24 List all activities that you used to do but now you cannot do them at all, and list all activities that you used to do that are now hard to do because of your injuries.
Question 24: List activities that are harder for you to do because of the crash that you used to do before the crash. This is a pretty straight forward question about what activities you used to do, but are now limited or impossible for you to do. The tricky part of this question that they will ask later is "how often did you do these activities before the accident?" They hope to show that you did not do that activity much, or it has been many years before this accident that you did that activity. So, try to list things that you did often, or at least once per year but now you cannot do them at all because of the injuries from this car crash.
The following things I used to do before the crash, but now I cannot do these things at all:* If you absolutely cannot do something that you used to do before check it. If you can do the activity but it is hard to do now, do not check the item, it will be asked next.
Describe the things you used to do before the crash but now you CANNOT do these things. Tell us how often you used to do them before and why you can't do them at all now.*
The following things I used to do before the crash, and now I can still do them but with great difficulty:* If you absolutely cannot do something that you used to do before check it. If you can do the activity but it is hard to do now, do not check the item, it will be asked next.
Describe the things you do now with great difficulty. Tell us how often you did the activity before the crash, and how the crash has made this harder for you to do.
Please add any other activities that you have great difficulty doing now because of the crash, and tell us why this crash has made these activities harder to do now.
Question 25 List all gyms and or health clubs you were a member over the past 5 years:
Question 25: List all gym memberships for the past 5 years. Please give us a list of all health clubs you were a member of over the past 5 years. This information will help show how active and healthy you were before the car crash.
check off all that apply:* What other gym, exercise, fitness or health club have you been a member in the past 5 years.*
Question 26 What was your cell phone number, carrier, and name of the account for your cell phone on the date of the accident?
Question 26: Who was your cell phone carrier at the time of the crash? The insurance defense lawyer may subpoena your cell phone records to see if you were using your cell phone at the time of the accident.
My cell phone number at the time of the crash was:
The cell phone carrier was: My cell phone bill was in the name of:
What name was the cell phone bill in at the time of the crash?
My cell phone account number is:
Please give us your cell phone account number so that we can order your phone record for the day of the crash if we need it.
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