Form 218

(c) Your average, weekly earnings, salary, or income received from said employment for the year preceding the date of the negligence alleged in the Complaint; (d) The date following the date of the negligence alleged in the Complaint on which you resumed the duties of said employment; (e) Any loss of income you claim resulted from the negligence alleged in your Complaint and how the loss is computed; (f) The dates you were unable to perform the duties and lost time from work as a result of injuries or conditions claimed to have been sustained as a result of the negligence alleged in your Complaint; and (g) The name and address of each employer for whom you worked for three years prior to the date of the negligence alleged in your Complaint. (28) Do you claim an impairment of earning capacity? (29) State whether you made an application(s) for life/disability insurance in the past ten years, and if so state the date of the application(s). (30) Identify the administrative/funeral and burial expenses incurred on behalf of the Plaintiff, if appli­ cable, as well as the date such expenses were incurred, the recipient of such monies and the identity of the individual who paid such expenses. (31) If you are introducing the condition of your mental health as an element of a claim in this lawsuit, state whether you have sought treatment with a mental health provider, including but not limited to a psychiatrist, psychologist, therapist, or counselor, in the ten years prior to, or subsequent to the negli­ gence alleged in the Complaint. COMMENT: Where appropriate, and where the Plaintiff does not consent to the production of the mental health records, the Defendant may seek a court order for the production of the records. (32) Has any treating physician or other health care provider told you directly that the above-named Defendant(s) failed to adhere to the acceptable standard of care in any respect? (33) If the answer to the preceding interrogatory is in the affirmative, state the name and address of each such physician or health care provider, the date each communication was made and the content of any such communication. (34) 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 negligence alleged in your Complaint, state in whose favor it was given, the date thereof, and to the extent it is not subject to a confidentiality agreement, the consideration paid to you for giving it. If you are unable to respond to this interrogatory, in whole or in part, due to a confidentiality agreement, state so. (35) If you or anyone on your behalf agreed to or contracted 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 negligence alleged in your Complaint, state in whose favor it was given, the date thereof, and to the extent it is not subject to a confidentiality agreement, the consid­ eration paid to you for giving it. If you are unable to respond to this interrogatory due to a confidentiality agreement, state so.