Form 217. Interrogatories—

Interrogatories— Civil Actions Alleging Personal Injury— Medicare Enrollment, Eligibility and Payments No. CV- : SUPERIOR COURT (Plaintiff) : JUDICIAL DISTRICT OF VS. : AT (Defendant) : (Date) The undersigned, on behalf of the , hereby propounds the following interrogatories to be answered under oath by the party being served within sixty (60) days of the service hereof in compliance with Practice Book Section 13-2. Definition: ‘‘You’’ shall mean the party 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 party’s decedent, ward or incapable person unless the context of an interrogatory clearly indicates otherwise. In answering these interrogatories, You are required to provide all information within your 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 the following: (a) your full name; (b) any other name(s) by which You have been known; (c) your date of birth; (d) your home address; (e) your business address. (2) State whether You have ever been enrolled in a plan offered pursuant to any Medicare Part. If your answer to Interrogatory #2 is affirmative, state the following: (a) the effective date(s); (b) your Medicare claim number(s); (c) your name exactly as it appears on your Medicare card. (3) State whether a plan offered pursuant to any Medicare Part has paid any bills for treatment of any injuries allegedly sustained as a result of the incident alleged in your complaint. If your answer to Interrogatory #3 is affirmative, state the amount paid. (4) If You are not presently enrolled in any Medicare Part, state whether You are eligible to enroll. (5) If You are not presently enrolled in any Medicare Part, state whether You plan to apply within the next thirty-six (36) months.