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Filing # 119870538 E-Filed 01/19/2021 05:02:24 PM
IN THE CIRCUIT COURT OF THE 17TH
DISTRICT IN AND FOR BROWARD
COUNTY, FLORIDA
CASE NO.: CACE-20-017319
LUIS MORENO and MARY BEATRICE
RAMOS, a married couple,,
Plaintiffs,
Vv.
BANTA PROPERTIES, INC., and
COLONIAL PARK APARTMENTS, LLC,
Defendants.
/
DEFENDANT’S NOTICE OF SERVING FIRST SET OF INTERROGATORIES TO LUIS
MORENO
The Defendant, BANTA PROPERTIES, INC. through undersigned counsel and
pursuant to Fla. R. Civ. P. 1.340, propounds the attached Interrogatories to the Plaintiff,
Luis Moreno, to be answered in accordance with the Florida Rules of Civil Procedure.
CERTIFICATE OF SERVICE
| HEREBY CERTIFY that on this 19th day of January, 2021, a true and correct
copy of the foregoing was filed with the Clerk of Broward County by using the Florida
Courts e-Filing Portal, which will send an automatic e-mail message to the following
parties registered with the e-Filing Portal system: Stuart H. Share, Esq., The Law Firm
of Stuart H. Share, P.A.,
stuart@sharelawpa.com;emely@sharelawpa.com;amanda@sharelawpa.com, 1000
Brickell Avenue, Suite 600, Miami, FL 33131, (305) 371-8700, Attorney for Plaintiffs, Mary
Beatrice Ramos and Luis Moreno.
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX
*** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 01/19/2021 05:02:23 PM.****1989.0474-00/22441414
By:
CASE NO.: CACE-20-017319
COLE, SCOTT & KISSANE, P.A.
Counsel for Defendant BANTA PROPERTIES,
INC. and COLONIAL PARK APARTMENTS,
LLC.
110 Tower
110 S.E. 6th Street, Suite 2700
Fort Lauderdale, Florida 33301
Telephone (954) 703-3763
Facsimile (954) 703-3701
Primary e-mail: patrick. mccardle@csklegal.com
Secondary e-mail: lindsay.adler@csklegal.com
Alternate e-mail:
annette.habersham@csklegal.com
s/ Lindsay A. Adler
PATRICK C. MCCARDLE
Florida Bar No.: 99042
LINDSAY A. ADLER
Florida Bar No.: 1010168
Page 2
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319
INTERROGATORIES TO PLAINTIFF LUIS MORENO
What is the name and address of the person answering these interrogatories, and,
if applicable, the person's official position or relationship with the party to whom
the interrogatories are directed?
List all former names and when you were known by those names. State all
addresses where you have lived for the past 10 years, the dates you lived at each
address, your Social Security number, your date of birth, and, if you are or have
ever been married, the name of your spouse or spouses.
List the names, business addresses, dates of employment, and rates of pay
regarding all employers, including self-employment, for whom you have worked in
the past 10 years.
Page 3
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX4.
CASE NO.: CACE-20-017319
Do you wear glasses, contact lenses, or hearing aids? If so, who prescribed them,
when were they prescribed, when were your eyes or ears last examined, and what
is the name and address of the examiner?
Have you ever been convicted of a crime, other than any juvenile adjudication,
which under the law under which you were convicted was punishable by death or
imprisonment in excess of 1 year, or that involved dishonesty or a false statement
regardless of the punishment? If so, state as to each conviction the specific crime
and the date and place of conviction.
Were you suffering from physical infirmity, disability, or sickness at the time of the
incident described in the complaint? If so, what was the nature of the infirmity,
disability, or sickness?
Page 4
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319
Did you consume any alcoholic beverages or take any drugs or medications within
12 hours before the time of the incident described in the complaint? If so, state
the type and amount of alcoholic beverages, drugs, or medication which were
consumed, and when and where you consumed them.
Describe in detail how the incident described in the complaint happened, including
all actions taken by you to prevent the incident.
Describe in detail each act or omission on the part of any party to this lawsuit that
you contend constituted negligence that was a contributing legal cause because
of the incident in question.
Page 5
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX10.
11.
12.
CASE NO.: CACE-20-017319
Were you charged with any violation of law (including any regulations or
ordinances) arising out of the incident described in the complaint? If so what was
the nature of the charge; what plea or answer, if any, did you enter to the charge;
what court or agency heard the charge; was any written report prepared by anyone
regarding this charge, and if so, what is the name and address of the person or
entity that prepared the report; do you have a copy of the report; and was the
testimony at any trial, hearing, or other proceeding on the charge recorded in any
manner, and, if so, what is the name and address of the person who recorded the
testimony?
Describe each injury for which you are claiming damages in this case, specifying
the part of your body that was injured, the nature of the injury, and, as to any
injuries you contend are permanent, the effects on you that you claim are
permanent.
List each item of expense or damage, other than loss of income or earning
capacity, that you claim to have incurred as a result of the incident described in the
Page 6
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX13.
14.
15.
CASE NO.: CACE-20-017319
complaint, giving for each item the date incurred, the name and business address
of the person or entity to whom each was paid or is owed, and the goods or
services for which each was incurred.
Do you contend that you have lost any form of income, benefits, or earning capacity
in the past or future as a result of the incident described in the complaint? If so,
state the nature of the income, benefits, or earning capacity, and the amount and
the method that you used in computing the amount.
Has anything been paid or is anything payable from any third party for the damages
listed in your answers to these interrogatories? If so, state the amounts paid or
payable, the name and business address of the person or entity who paid or owes
said amounts, and which of those third parties have or claim a right of subrogation.
List the names and business addresses of each physician who has treated or
examined you and each medical facility where you have received any treatment or
examination for the injuries for which you seek damages in this ease; and state as
Page 7
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX16.
17.
18.
CASE NO.: CACE-20-017319
to each the date of treatment or examination and the injury or condition for which
you were examined or treated.
List the names and business addresses of all other physicians, medical facilities,
or other health care providers by whom or at which you have been examined or
treated in the past 10 years; and state as to each the dates of examination or
treatment and the condition or injury for which you were examined or treated.
List the names and addresses of all persons who are believed or known by you,
your agents, or your attorneys to have any knowledge concerning any of the issues
in this lawsuit; and specify the subject matter about which the witness has
knowledge.
Have you heard or do you know about any statement or remark made by or on
behalf of any party to this lawsuit, other than yourself, concerning any issue in this
lawsuit? If so, state the name and address of each person who made the statement
or statements, the name and address of each person who heard it, and the date,
time, place, and substance of each statement.
Page 8
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX19.
20.
CASE NO.: CACE-20-017319
State the name and address of every person known to you, your agents, or your
attorneys, who has knowledge about, or possession, custody, or control of, any
model, plat, map, drawing, motion picture, videotape, or photograph pertaining to
any fact or issue involved in this controversy; and describe as to each, what item
such person has, the name and address of the person who took or prepared it,
and the date it was taken or prepared.
Do you intend to call any expert witnesses at the trial of this case? If so, state as
to each such witness the name and business address of the witness, the witness's
qualifications as an expert, the subject matter upon which the witness is expected
to testify, the substance of the facts and opinions to which the witness is expected
to testify, and a summary of the grounds for each opinion.
Page 9
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX21.
22.
23.
CASE NO.: CACE-20-017319
Have you made an agreement with anyone that would limit that party's liability to
anyone for any of the damages sued upon in this case? If so, state the terms of
the agreement and the parties to it.
Please state if you have ever been a party, either plaintiff or defendant in a lawsuit
other than the present matter, and, if so, state whether you were plaintiff or
defendant, the nature of the action, and the date and court in which such suit was
filed.
Have you ever declared bankruptcy and, if so, what was your case number? If
you do know your case number, please list all known information, including the
date and place of filing, the full name you filed under, your legal counsel, and the
date of resolution, if it has resolved.
Page 10
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX24.
25.
26.
CASE NO.: CACE-20-017319
Describe in detail the nature and extent of any limitation you now experience in
your ability to engage in any activities or perform any functions or duties as a
result of the incident described in the Complaint, and specify whether you are
partially or totally limited in any such activity, function or duty.
Describe in detail the nature and extent of any injuries or conditions that existed
prior to the date of the incident described in the Complaint and related to any of
the areas of your body to which you are complaining of injury in this case, and for
any such injury or condition, list the date of the injury or condition, area of the
body injured, the type of treatment received and the name and business address
of all medical providers or facilities that examined or rendered treatment for any
such injury or condition.
Please describe the item upon which you allegedly tripped or slipped upon at the
time of the incident in this case. Please also indicate whether there were any
other factors other than the item which you allegedly tripped or slipped that
contributed to your fall in this case.
Page 11
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX27.
28.
29.
CASE NO.: CACE-20-017319
Have you ever received a disability rating of any type whatsoever from any
individual or private governmental organization prior to or since the incident in
question, and not related to the incident in question? If so, state as to each the
name and address of the physician or organization giving such rating or ratings,
the date(s) of the rating(s), the amount of disability rating(s), and describe the
nature of the incident causing the disability.
Describe any and all accidents and/or injuries you suffered before the happening
of the alleged accident in this lawsuit. This question is not limited to automobile
accidents, but you are asked to describe any and all accidents of any kind.
(a) | As to each accident or injury, state the names and addresses of the other
parties involved, date and time it occurred, place it occurred, all injuries
you sustained. Names, addresses, and specialty, if any, of the treating
and consulting physicians, period of disability you sustained, and the
names and addresses of the hospitals or place of confinement in which
you were a patient in connection with such injuries.
Have you travelled on vacation or otherwise outside the tri-county area since the
subject incident. If so, please provide the dates of travel, the nature of the travel,
the names and contact information of any travel companions, and provide the
mode of travel for each trip.
Page 12
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319
By.
STATE OF FLORIDA )
Ss:
COUNTY OF BROWARD )
Sworn to and subscribed before me this day of 7
2021, by , who is personally known to me or who has
produced as identification.
NOTARY PUBLIC
TYPED NAME:
COMMISSION EXPIRES:
COMMISSION NO.:
Page 13
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319
Page 14
COLE, SCOTT & KISSANE, P.A.
110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX
Preview
Filing # 119870538 E-Filed 01/19/2021 05:02:24 PM IN THE CIRCUIT COURT OF THE 17TH DISTRICT IN AND FOR BROWARD COUNTY, FLORIDA CASE NO.: CACE-20-017319 LUIS MORENO and MARY BEATRICE RAMOS, a married couple,, Plaintiffs, Vv. BANTA PROPERTIES, INC., and COLONIAL PARK APARTMENTS, LLC, Defendants. / DEFENDANT’S NOTICE OF SERVING FIRST SET OF INTERROGATORIES TO LUIS MORENO The Defendant, BANTA PROPERTIES, INC. through undersigned counsel and pursuant to Fla. R. Civ. P. 1.340, propounds the attached Interrogatories to the Plaintiff, Luis Moreno, to be answered in accordance with the Florida Rules of Civil Procedure. CERTIFICATE OF SERVICE | HEREBY CERTIFY that on this 19th day of January, 2021, a true and correct copy of the foregoing was filed with the Clerk of Broward County by using the Florida Courts e-Filing Portal, which will send an automatic e-mail message to the following parties registered with the e-Filing Portal system: Stuart H. Share, Esq., The Law Firm of Stuart H. Share, P.A., stuart@sharelawpa.com;emely@sharelawpa.com;amanda@sharelawpa.com, 1000 Brickell Avenue, Suite 600, Miami, FL 33131, (305) 371-8700, Attorney for Plaintiffs, Mary Beatrice Ramos and Luis Moreno. COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX *** FILED: BROWARD COUNTY, FL BRENDA D. FORMAN, CLERK 01/19/2021 05:02:23 PM.****1989.0474-00/22441414 By: CASE NO.: CACE-20-017319 COLE, SCOTT & KISSANE, P.A. Counsel for Defendant BANTA PROPERTIES, INC. and COLONIAL PARK APARTMENTS, LLC. 110 Tower 110 S.E. 6th Street, Suite 2700 Fort Lauderdale, Florida 33301 Telephone (954) 703-3763 Facsimile (954) 703-3701 Primary e-mail: patrick. mccardle@csklegal.com Secondary e-mail: lindsay.adler@csklegal.com Alternate e-mail: annette.habersham@csklegal.com s/ Lindsay A. Adler PATRICK C. MCCARDLE Florida Bar No.: 99042 LINDSAY A. ADLER Florida Bar No.: 1010168 Page 2 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319 INTERROGATORIES TO PLAINTIFF LUIS MORENO What is the name and address of the person answering these interrogatories, and, if applicable, the person's official position or relationship with the party to whom the interrogatories are directed? List all former names and when you were known by those names. State all addresses where you have lived for the past 10 years, the dates you lived at each address, your Social Security number, your date of birth, and, if you are or have ever been married, the name of your spouse or spouses. List the names, business addresses, dates of employment, and rates of pay regarding all employers, including self-employment, for whom you have worked in the past 10 years. Page 3 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX4. CASE NO.: CACE-20-017319 Do you wear glasses, contact lenses, or hearing aids? If so, who prescribed them, when were they prescribed, when were your eyes or ears last examined, and what is the name and address of the examiner? Have you ever been convicted of a crime, other than any juvenile adjudication, which under the law under which you were convicted was punishable by death or imprisonment in excess of 1 year, or that involved dishonesty or a false statement regardless of the punishment? If so, state as to each conviction the specific crime and the date and place of conviction. Were you suffering from physical infirmity, disability, or sickness at the time of the incident described in the complaint? If so, what was the nature of the infirmity, disability, or sickness? Page 4 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319 Did you consume any alcoholic beverages or take any drugs or medications within 12 hours before the time of the incident described in the complaint? If so, state the type and amount of alcoholic beverages, drugs, or medication which were consumed, and when and where you consumed them. Describe in detail how the incident described in the complaint happened, including all actions taken by you to prevent the incident. Describe in detail each act or omission on the part of any party to this lawsuit that you contend constituted negligence that was a contributing legal cause because of the incident in question. Page 5 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX10. 11. 12. CASE NO.: CACE-20-017319 Were you charged with any violation of law (including any regulations or ordinances) arising out of the incident described in the complaint? If so what was the nature of the charge; what plea or answer, if any, did you enter to the charge; what court or agency heard the charge; was any written report prepared by anyone regarding this charge, and if so, what is the name and address of the person or entity that prepared the report; do you have a copy of the report; and was the testimony at any trial, hearing, or other proceeding on the charge recorded in any manner, and, if so, what is the name and address of the person who recorded the testimony? Describe each injury for which you are claiming damages in this case, specifying the part of your body that was injured, the nature of the injury, and, as to any injuries you contend are permanent, the effects on you that you claim are permanent. List each item of expense or damage, other than loss of income or earning capacity, that you claim to have incurred as a result of the incident described in the Page 6 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX13. 14. 15. CASE NO.: CACE-20-017319 complaint, giving for each item the date incurred, the name and business address of the person or entity to whom each was paid or is owed, and the goods or services for which each was incurred. Do you contend that you have lost any form of income, benefits, or earning capacity in the past or future as a result of the incident described in the complaint? If so, state the nature of the income, benefits, or earning capacity, and the amount and the method that you used in computing the amount. Has anything been paid or is anything payable from any third party for the damages listed in your answers to these interrogatories? If so, state the amounts paid or payable, the name and business address of the person or entity who paid or owes said amounts, and which of those third parties have or claim a right of subrogation. List the names and business addresses of each physician who has treated or examined you and each medical facility where you have received any treatment or examination for the injuries for which you seek damages in this ease; and state as Page 7 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX16. 17. 18. CASE NO.: CACE-20-017319 to each the date of treatment or examination and the injury or condition for which you were examined or treated. List the names and business addresses of all other physicians, medical facilities, or other health care providers by whom or at which you have been examined or treated in the past 10 years; and state as to each the dates of examination or treatment and the condition or injury for which you were examined or treated. List the names and addresses of all persons who are believed or known by you, your agents, or your attorneys to have any knowledge concerning any of the issues in this lawsuit; and specify the subject matter about which the witness has knowledge. Have you heard or do you know about any statement or remark made by or on behalf of any party to this lawsuit, other than yourself, concerning any issue in this lawsuit? If so, state the name and address of each person who made the statement or statements, the name and address of each person who heard it, and the date, time, place, and substance of each statement. Page 8 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX19. 20. CASE NO.: CACE-20-017319 State the name and address of every person known to you, your agents, or your attorneys, who has knowledge about, or possession, custody, or control of, any model, plat, map, drawing, motion picture, videotape, or photograph pertaining to any fact or issue involved in this controversy; and describe as to each, what item such person has, the name and address of the person who took or prepared it, and the date it was taken or prepared. Do you intend to call any expert witnesses at the trial of this case? If so, state as to each such witness the name and business address of the witness, the witness's qualifications as an expert, the subject matter upon which the witness is expected to testify, the substance of the facts and opinions to which the witness is expected to testify, and a summary of the grounds for each opinion. Page 9 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX21. 22. 23. CASE NO.: CACE-20-017319 Have you made an agreement with anyone that would limit that party's liability to anyone for any of the damages sued upon in this case? If so, state the terms of the agreement and the parties to it. Please state if you have ever been a party, either plaintiff or defendant in a lawsuit other than the present matter, and, if so, state whether you were plaintiff or defendant, the nature of the action, and the date and court in which such suit was filed. Have you ever declared bankruptcy and, if so, what was your case number? If you do know your case number, please list all known information, including the date and place of filing, the full name you filed under, your legal counsel, and the date of resolution, if it has resolved. Page 10 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX24. 25. 26. CASE NO.: CACE-20-017319 Describe in detail the nature and extent of any limitation you now experience in your ability to engage in any activities or perform any functions or duties as a result of the incident described in the Complaint, and specify whether you are partially or totally limited in any such activity, function or duty. Describe in detail the nature and extent of any injuries or conditions that existed prior to the date of the incident described in the Complaint and related to any of the areas of your body to which you are complaining of injury in this case, and for any such injury or condition, list the date of the injury or condition, area of the body injured, the type of treatment received and the name and business address of all medical providers or facilities that examined or rendered treatment for any such injury or condition. Please describe the item upon which you allegedly tripped or slipped upon at the time of the incident in this case. Please also indicate whether there were any other factors other than the item which you allegedly tripped or slipped that contributed to your fall in this case. Page 11 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX27. 28. 29. CASE NO.: CACE-20-017319 Have you ever received a disability rating of any type whatsoever from any individual or private governmental organization prior to or since the incident in question, and not related to the incident in question? If so, state as to each the name and address of the physician or organization giving such rating or ratings, the date(s) of the rating(s), the amount of disability rating(s), and describe the nature of the incident causing the disability. Describe any and all accidents and/or injuries you suffered before the happening of the alleged accident in this lawsuit. This question is not limited to automobile accidents, but you are asked to describe any and all accidents of any kind. (a) | As to each accident or injury, state the names and addresses of the other parties involved, date and time it occurred, place it occurred, all injuries you sustained. Names, addresses, and specialty, if any, of the treating and consulting physicians, period of disability you sustained, and the names and addresses of the hospitals or place of confinement in which you were a patient in connection with such injuries. Have you travelled on vacation or otherwise outside the tri-county area since the subject incident. If so, please provide the dates of travel, the nature of the travel, the names and contact information of any travel companions, and provide the mode of travel for each trip. Page 12 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319 By. STATE OF FLORIDA ) Ss: COUNTY OF BROWARD ) Sworn to and subscribed before me this day of 7 2021, by , who is personally known to me or who has produced as identification. NOTARY PUBLIC TYPED NAME: COMMISSION EXPIRES: COMMISSION NO.: Page 13 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAXCASE NO.: CACE-20-017319 Page 14 COLE, SCOTT & KISSANE, P.A. 110 TOWER - 110 S.E. 6TH STREET, SUITE 2700 - FT. LAUDERDALE, FLORIDA 33301 (954) 703-3700 (954) 703-3701 FAX