Form 214

(30) Do you claim an impairment of earning capacity? (31) List any other expenses or loss and the amount thereof not already set forth and which you claim to have incurred as a result of the incident alleged in your Complaint. (32) If you have signed a covenant not to sue, a release or discharge of any claim you had, have or may have against any person, corporation or other entity as a result of the incident alleged in your Complaint, please state in whose favor it was given, the date thereof, and the consideration paid to you for giving it. (33) If you or anyone on your behalf agreed or made an agreement with any person, corporation or other entity to limit in any way the liability of such person, corporation or other entity as a result of any claim you have or may have as a result of the incident alleged in your Complaint, please state in whose favor it was given, the date thereof, and the consideration paid to you for giving it. (34) If, since the date of the incident alleged in your Complaint, you have made any claims for workers’ compensation benefits as a result of the incident alleged in your Complaint: (a) State the nature of such claims and the dates on which they were made. (b) 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. (c) 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 #34, 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. (d) 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. (e) 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 #34. (f) Which of your claims arising out of the incident/occurrence alleged in the Complaint and referenced in your answer to Interrogatory #34 are still open? (35) Have you made any statements, as defined in Practice Book Section 13-1, to any person regarding any of the events or happenings alleged in your Complaint? (36) State the names and addresses of all persons known to you who were present at the time of the incident alleged in your Complaint or who observed or witnessed all or part of the incident. (37) As to each individual named in response to Interrogatory #36, state whether to your knowledge, or the knowledge of your attorney, such individual has given any statement or statements as defined in Practice Book Section 13-1 concerning the subject matter of the Complaint in this action. If the answer to this interrogatory is affirmative, state also: (a) The date on which the statement or statements were taken;