Form 5. Uniform Personal Injury Interrogatories
Arizona Revised Statutes AnnotatedRules of Civil Procedure for the Superior Courts of Arizona
16 A.R.S. Rules of Civil Procedure, Form 5
Form 5. Uniform Personal Injury Interrogatories
INSTRUCTIONS FOR USE
INTERROGATORIES
Interrogatory No. 1: State your name and address or principal place of business, date of birth, and social security number.
Interrogatory No. 2: Have you been convicted of a felony? ___ If so, for each felony state:
Interrogatory No. 3: Have you ever been a party to a civil lawsuit? ___ If so, state:
Interrogatory No. 4: State exactly and in detail your version of how this accident occurred.
Interrogatory No. 5: State specifically and in detail the facts upon which your contention is based that the accident was caused by a negligent conduct of another party, including former parties, or non-party.
Interrogatory No. 6: Was an investigation conducted concerning the accident in question? ___ If so, state:
Interrogatory No. 7: Do you know of any person who is skilled in any particular field or science, including the field of medicine, whom you may call as a witness upon the trial of this action and who has expressed an opinion upon any issue of this action? ___ If so, state:
Interrogatory No. 8: Describe in detail all injuries, whether physical, mental, or emotional, experienced since the occurrence and claimed to have been caused, aggravated, or otherwise contributed to by it.
Interrogatory No. 9: For all injuries mentioned in the proceeding interrogatory, please identify those injuries which are considered by you to be permanent.
Interrogatory No. 10: As to each medical practitioner who has examined or treated any of the persons named in your answers to Interrogatory No. 1 above, for any of the injuries or symptoms described, state:
Interrogatory No. 11: State as to each item of medical expense attributable to the accident:
Interrogatory No. 12: List each injury, symptom, or complaint mentioned in answer to Interrogatory No. 8 from which you suffered at any time before the accident.
Interrogatory No. 13: Do you claim to have lost any time from gainful employment as a result of the accident? ___ If so, state:
Interrogatory No. 14: If your answer to Interrogatory No. 13 is yes, list each job or position of employment including self-employment, held by you on the date of and since the accident, stating as to each, the following:
Interrogatory No. 15: Do you claim that your ability to engage in any type of gainful employment has been affected by the accident? ___ If so, state:
Interrogatory No. 16: Provide the identity and location of any nonparty identified in your response to Interrogatory No. 5 above, who you claim, pursuant to A.R.S. § 12-2506(B) (as amended), was wholly or partially at fault in causing any personal injury, property damage, or wrongful death for which damages are sought in this action.
Interrogatory No. 17: Do you have liability insurance or are you aware of any other form of indemnity which you claim is applicable to this accident? ___ If the answer is yes, state:
Interrogatory No. 18: State the name, address, and occupation of the owner of any vehicles you allege caused damage to the plaintiff.
Interrogatory No. 19: At the time of the alleged accident, was the driver of said vehicle engaged in the business of any other person or entity? ___ If so, please state the name and address of such other person or entity.
Interrogatory No. 20: State whether you or anyone else involved in the accident ingested or used any drugs or medications within 48 hours prior to the accident or drank any intoxicating beverages of any kind within the 12 hours prior to the accident or to the occurrence of the accident alleged in the Complaint. ___ If so, state the times, places, amount, and type of drugs or alcoholic beverages.
Interrogatory No. 21: Do there exist any liens, including AHCCCS, Medicare, or any liens provided for by A.R.S. § 33-931 et seq., on any recovery you may have or may obtain in this matter? ___ If so, give the amount and entity holding such lien and the nature of said lien.
Interrogatory No. 22: If the accident that is the subject of the plaintiff's claim was a automobile accident, please state the following:
Credits
Added Sept. 2, 2016, effective Jan. 1, 2017.
16 A. R. S. Rules Civ. Proc., Form 5, AZ ST RCP Form 5
State Court Rules are current with amendments received through August 15, 2024. The Code of Judicial Administration is current with amendments received through August 1, 2024.
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