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PLAINTIFF’S NOTICE OF SERVING ANSWERS TO INTERROGATORIES BY DEFENDANT


IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT IN AND FOR BROWARD COUNTY, FLORIDA

CASE NO. XX

ROBERT JONES,

 

Plaintiff,

 

vs.

 

AMUSEMENT PARKS, LLC.,

 

Defendant.

_______________________________________/

PLAINTIFF’S NOTICE OF SERVING ANSWERS TO INTERROGATORIES BY DEFENDANT

The Plaintiff, ROBERT JONES, pursuant to Rule 1.340, Florida Rules of Civil Procedure, hereby gives Notice of Serving Answers to Interrogatories propounded by Defendant, AMUSEMENT PARKS, LLC., dated XX, 20__.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a copy of the foregoing has been furnished by hand-delivery this _____ day of XX, 20__ to: XX

LAW OFFICE OF ALAN D. SACKRIN

Attorney for Plaintiff

2100 East Hallandale Beach Blvd./Ste 200

Hallandale Beach, FL  33009

 

By:                                                              

ALAN D. SACKRIN

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COLLATERAL SOURCE INTERROGATORIES

 

  1. Please state whether you, or anyone acting on your behalf, has made any application or claim against any insurance company, worker=s compensation insurer, or governmental entity or agency for benefits for medical expenses by virtue of any injuries allegedly sustained as a result of the subject incident.

XX

  1. If your answer to the foregoing interrogatory was in the affirmative, please further set forth: XX

 

  1. The name and address of each insurer or governmental entity to whom such application was directed.

 

  1. Your policy number and the claim number assigned to each such claim:

 

  1. The date the medical expense was submitted to the insurer or governmental entity.

 

  1. As to each medical bill incurred, provide the information on the attached Schedule A, @ (copies of bills are not sufficient):

 

  1. Have you or has anyone acting on your behalf made any application or claim against any insurance company, worker=s compensation insurer, or governmental entity or agency for any non-medical benefit (i.e., lost wages, disability income, etc.), by virtue of the injuries allegedly sustained in the incident which is the subject of the plaintiff=s complaint?

XX

  1. If your answer to the foregoing interrogatory was in the affirmative, please further set forth: XX

 

  1. The name and address of each insurer or governmental entity to whom any such application was directed;

 

  1. Your policy number and/or the claim number assigned at each such claim;

 

  1. The status of the application of claim (accepted, rejected, pending);

 

  1. If accepted, the amount that you have been paid and the amount that you expect to be paid (if monthly payment, state the amount).

 

  1. Please state whether on the date of the subject incident you were working within the course and scope of your employment at the time of the incident. If so, please state whether or not your employer had Worker=s Compensation Benefits in place and identify the name of the carrier sufficient to allow additional discovery in this regard.

XX

  1. Please state whether or not with respect to the subject incident you have received any payment or benefits from the United States Social Security Act, any federal, state, or local income disability act, or any other public programs providing medical expenses, disability payments or other similar benefits. If so, please identify the date of the application, the amount of payment and the source with specificity and for what payment was rendered.

XX

  1. Have you received any other payment of any funds whatsoever, from any source including family and friends, relating to the injuries allegedly sustained as a result of the incident which is the subject matter of the complaint?

XX

  1. If your answer to the foregoing interrogatory was in the affirmative, please further set forth: XX

 

  1. The name and address of any person or entity who has made such payment;

 

  1. The reason what such person or entity made such payment;

 

  1. The total amount received to date from each such person or entity, and the date(s) the funds were received;

 

  1. Whether you expect such payment or payments to continue in the future; and

 

  1. If you do not expect such payments to continue in the future, the reason why you expect such payments to terminate.

 

  1. Please state whether any collateral source provided pursuant to Florida Statute 768.76(6) was sent a notification of claimant’s intent to claim damages from the tortfeasor by either certified or registered mail. If so, did the collateral source provider waive any right of subrogation or reimbursement by failing to provide a statement asserting its payment of collateral source benefits and its right of subrogation or reimbursement within 30 days after receipt of the claimant=s notification of intent to claim damages from the tortfeasor pursuant to Florida Statute Section 768.76(7)?

XX

  1. List the total amount of medical bills and/or other expenses related to the incident described in the subject complaint, the amounts submitted to any collateral source provider, the amount paid by the collateral source provider, and the amount that was disallowed or adjusted.

XX

  1. List the total amount of any medical bills or expenses that were not paid by any collateral source provider pursuant to Florida Statute Section 768.76.

XX

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The pleading above is a sample document related to a specific set of facts and circumstances and should not be used or relied upon for any personal injury matter. This document is being provided for illustrative purposes only. We recommend and urge you to consult with an experienced personal injury lawyer for professional advice as each case is unique.

To Learn About Alan’s Qualifications as a Personal Injury Lawyer, See His About Me Page.