SAMPLE Juror Questionnaire Insurance by dSuS0V3Y

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									Following is a sample supplemental juror questionnaire (SJQ) for insurance cases. The cover page and many
of the items on the SJQ are standard and may be used as a template for any type of case (demographics,
attitudes toward the legal system, leadership). Other questions are case specific. As items are deleted, the
question numbers will update automatically. For the most accurate use of an SJQ, work with the specific facts
of your case (and possibly a trial consultant).

If you would like assistance using a juror questionnaire, please contact Richelle Lyon at Los Angeles Legal
Strategy at rlyon@lalegalstrategy.com or 310-424-0875. Tips and strategies for implementing and analyzing
jury questionnaires can be found at www.lalegalstrategy.com

Almost any case can benefit from a supplemental juror questionnaire (SJQ) because:
       You will have more time to carefully consider strikes and challenges as compared to oral voir dire
        alone, and more information to form the basis of your decisions

       You will have the opportunity to accurately capture all prospective jurors’ answers to questions
        (instead of attempting to count raised hands and jot down oral responses)

       You will have the opportunity to develop appropriate, targeted follow up voir dire questions based
        on the specific jury pool’s unique responses to written questions

       The quality and quantity of responses will increase because both the fear of public speaking and the
        drift of conformity are removed

       You will gain significantly more information about each prospective juror’s facility with the English
        language, literacy, and ability to follow directions

Basic Tips:
       Submit to the court a final SJQ that is as short as possible, and be prepared with a list of questions
        you’re willing to “sacrifice” so the court does not decide for you

       Always attempt to reach agreement with the other side about the usage and content of the SJQ
        before approaching the court because that will greatly increase the likelihood of its acceptance

       Often, you will want to intentionally draft your version of the SJQ with items you are prepared to
        remove as part of strategic bargaining with the other side, especially if you anticipate wanting to
        remove some of theirs

       Seek a balance between questions that identify your worst jurors without revealing too much of your
        strategy to the other side

       Try to have the questionnaires mailed to prospective jurors instead of having them filled out in court,
        as this will allow the maximum amount of time for analysis

       Offer to pay for the administration (postage and photocopying) of the questionnaires

       Prepare a Motion that persuades the judge that the SJQ will save the court time and money and
        increase the likelihood of a fair trial
                                    TO PROSPECTIVE JURORS

          You have been selected as a potential juror in the case of XXXXX v. XXXXX. This
  questionnaire is designed to obtain information regarding your qualifications to sit as a juror in
  this case. The use of this questionnaire will significantly shorten your time in the jury selection
  process. Please answer all questions by yourself, giving your best effort to answer each question
  thoughtfully and honestly. Please do not discuss this questionnaire with anyone except court
  personnel.

         Judge XXXXX will give you instructions on the law and on how you should go about
  deciding this case. You must listen to and follow the judge’s instructions. If there is any reason
  why you might not be able to give both sides a fair trial in this case, it is important to say so.
  Your honest and complete answers are needed to every single question on this questionnaire.
  You are expected to sign this questionnaire at the end, and your answers will have the effect of a
  statement given under oath to the Court.

           Please make your answers to the following questions as full and complete as possible. If
  you need assistance filling out any part of this questionnaire, please tell the jury clerk or court
  officers. Do not consult with any other person. If you have trouble reading, understanding or
  filling out any part of this questionnaire, please mark which questions are giving you difficulty
  and let the court clerk know.

           Please write in pen only. If you do not have a pen, please let the clerk know and you
  will be provided you with a pen. Do not leave any blanks. If a question is not relevant to you,
  write “NA” for “not applicable.” If you cannot understand a question, write “Do not understand”
  next it. If you do not know the answer to a question, write “Don’t know” next to it.

          Please write the word PRIVATE next to any question that you would like to answer
  privately. During the questioning by the attorneys, you may be given an opportunity to explain or
  expand upon your answers. This is an extremely time-consuming approach and should be
  reserved for only those questions that will personally cause extreme difficulty or embarrassment
  if answered in open court.

          If you wish to make further comments regarding any of your answers, use the page at the
  end of the questionnaire entitled “Additional Responses.” Please indicate the number of the
  question that you are continuing to answer along with your response.

        Please write clearly. If your answers are illegible you may be required to recopy your
  answers. When you have completed the questionnaire, please give it to the attendant.


PLEASE DO NOT LEAVE WITHOUT TURNING IN YOUR COMPLETED QUESTIONNAIRE

                                 Thank you for your full cooperation.




                                              Page 1 of 9
 Juror Name (First & Last): _____________________________                Juror Number: _________________________
 Gender: _____ Male _____Female                                          Date of Birth: _____Day _____ Month _____Year
 Place of Birth _________________________________________                Length of time at current address _____________

1. Current neighborhood/town (NOT exact address) _________________________________________________
2. Do you own or rent your residence? _____ Own _____Rent
3. Is English your first language? ____Yes ____No If NO, What was your first language?_________________
4. Marital Status:
      ___ Single (never married)              ___ Married (for ___years)
      ___ Separated                           ___ Divorced (___ times, ___ years since last divorce)
      ___ Significant partner (for ___ years) ___ Widowed
5. Current employment status: (Please check all that apply)
      ___ Employed Full-time               _____ Student (Area of study: _________________________)
      ___ Employed Part-time               _____ Disabled
      ___ Homemaker                        _____ Unemployed (looking for work)
      ___ Retired                          _____ Unemployed (not looking for work)
6. For the following section, reference your current job (If retired/unemployed/disabled, your most recent job)
     a.   Occupation _____________________________________________________________________________
     b.   Name of employer ________________________________________________________________________
     c.   Type of employer ___ Government _____ Private Business _____ Not for Profit
     d.   Type of employment ___ Full-time/salaried ___ Full-time,/hourly ___ Contractor/temporary ___ Part-time
     e.   Exact job title ___________________________________________________________________________
     f.   Length of time you have held (or did hold) this job                _____ Years _____ Months
     g.   Do/did you supervise other persons? ___Yes ___No                   If YES, how many? _____
     h.   Do/did you evaluate the performance of employees? ___ Yes ___No If YES, how many? _____
     i.   Do/did you hire and fire employees?                                ___ Yes ___No
7. Number of employers you have had over the past 10 years _______
8. Previous job titles over the past 10 years _________________________________________________________
   ____________________________________________________________________________________________
9. Have you, or anyone close to you, ever been self-employed, owned a business, or been an employer?
   ___ Yes ___No     If YES, please explain:
            a. The type of business_________________________________________________________________
            b. Beginning and end dates you owned/operated it ___________________________________________
            c. How long you owned/operated it_______________________________________________________
10. What is your significant other’s: (If single, please write “N/A”):
      a. Job/occupation: ___________________________________________________________________
      b. Educational background:____________________________________________________________
      c. If retired or unemployed, his/her prior occupation: _________________________________________
11. Please list your children and/or stepchildren: (If none, please write N/A)
           Gender                Age       Live with you?        Education        Occupation       Marital Status
    ___ Male ___ Female         _____     ___ Yes ___ No         _________        _____________    ___________
    ___ Male ___ Female         _____     ___ Yes ___ No         _________        _____________    ___________
    ___ Male ___ Female         _____     ___ Yes ___ No         _________        _____________    ___________
    ___ Male ___ Female         _____     ___ Yes ___ No         _________        _____________    ___________
    ___ Male ___ Female         _____     ___ Yes ___ No         _________        _____________    ___________
                                                     Page 2 of 9
12. Please list anyone else living in your home, their relationship to you, their age and their occupation:
    _____________________________________________________________________________________
   _____________________________________________________________________________________
13. What is your highest completed level of education?
        ___ Less than high school              ___ Tech school degree (Field: ___________________________)
        ___ Some high school                   ___ College degree (Major: ______________________________)
        ___ High school graduate               ___ Some graduate school (Major: ________________________)
        ___ Some college/Technical school      ___ Post graduate degree (Major: ________________________)
14. Have you, or anyone close to you, ever studied or received training in any of the following areas?
    Justice system     ___ Yes ___ No If yes, please explain: ___________________________________________
    Law/Legal           ___Yes ___ No If yes, please explain: ___________________________________________
    Law enforcement    ___ Yes ___ No If yes, please explain: ___________________________________________
    Religion/Ethics     ___ Yes ___ No If yes, please explain: __________________________________________
15. Please list all groups or organizations in which you participate or are a member. For example, service clubs,
    church or church groups, professional organizations, volunteer activities, educational or political groups,
    neighborhood groups, or self-help groups: _______________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
16. Have you ever held a leadership position in any organization listed above? ___ Yes ___No
    If YES, please explain: _________________________________________________________________________
17. Have you, or anyone close to you, ever served in the military? _____ Yes ___No If YES, please list:
     a. Who: __________________ Branch of service: _______________________ Years of service: _____
     b. Who: __________________ Branch of service: _______________________ Years of service: _____
18. Have you, or anyone close to you, ever been a member of any union? ___ Yes ___No         If YES, please list:
     a. Union: _______________________________ Years of membership: ______________________
     b. Union: _______________________________ Years of membership: ______________________
19. Do you consider yourself to be aligned more closely with one political party? ___ Yes ___No
    Which one? __________________________________________________________________________________
20. Have you ever campaigned, volunteered or worked at any political campaign office? ___ Yes ___No
    If YES, please explain where, when and in what capacity: __________________________________________
    ____________________________________________________________________________________________
21. Please list 3 of your favorite hobbies, interests, recreational pastimes, or spare time activities:
        1. _____________________________________________________________________________________
        2. _____________________________________________________________________________________
        3. _____________________________________________________________________________________
22. Please list your Top 3 favorite TV shows:
        1. _____________________________________________________________________________________
        2. _____________________________________________________________________________________
        3. _____________________________________________________________________________________
23. Please list all of your magazine and/or newspaper subscriptions: _____________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________




                                                    Page 3 of 9
24. Have you or anyone close to you ever suffered a long-term or permanent disability? ____ Yes ___No
    If YES, please explain: ________________________________________________________________________
   ____________________________________________________________________________________________
25. Have you or anyone close to you ever been involved in a lawsuit, either as a party or witness in court, or by
    deposition, including a divorce? ___ Yes ___No            If YES: ___ Did you sue ___ Were you sued?
   What was the case about?_______________________________________________________________________
   Were you satisfied with the result?________________________________________________________________
26. Have you or anyone close to you ever considered suing someone, but did not for some reason?
   ___ Yes ___No   If YES, please explain_________________________________________________________
   ____________________________________________________________________________________________
27. Have you or anyone close to you ever made ANY claim for personal injuries as a result of an injury or
    illness? ___ Yes ___No If YES, please explain___________________________________________________
     ___________________________________________________________________________________________
28. Do you consider yourself to be a leader, an opinion generator, or a supporter of others?
       ___ A leader     ___ An opinion generator      ___ A supporter of others
29. What are your PRIMARY sources of news? (Please select no more than 2 from the list below)
   ___ T.V. ___ Newspaper ___ Radio ___ Internet ___ Magazines ___ Word of mouth/friends ___ None
30. Have you ever served on a jury? ___YES ___NO If YES, please complete the section below:
                                       CASE #1              CASE #2                      CASE #3
    Year                            ________________    ________________            ________________
    Civil or criminal               ________________    ________________            ________________
    Type of case/Charges            ________________    ________________            ________________
    Were you the foreperson?        ________________    ________________            ________________
    Did the jury reach a verdict?   ________________    ________________            ________________
31. How did you feel about your jury experience? ____________________________________________________
    ____________________________________________________________________________________________
32. Have you ever held a leadership position in any organization? (If NO, write “N/A”)
     a. Organization: _____________________________________ Role: ______________________________
     b. Organization: _____________________________________ Role: ______________________________
     c. Organization: _____________________________________ Role: ______________________________
33. What do you think about people who file lawsuits because they feel that they have been injured or wronged
    by a person or company? ______________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
34. Do you have any insurance policies?     Yes____     No____
   If yes, please write the name of the insurance company, and underneath it please write the type of policy(s).
                      Company #1 _____________      Company #2 _____________         Company #3 _____________
   Type of Policy     ________________________      ________________________         ________________________
   Type of Policy     ________________________      ________________________         ________________________
   Type of Policy     ________________________      ________________________         ________________________




                                                   Page 4 of 9
35. Have you ever had any dealings with, or heard anything about the following companies:
   ABC Insurance Company                      Yes____      No____
   XYZ Insurance Company                      Yes____      No____
   A1 Insurance Adjusting Company             Yes____      No____
   XXXXX Corporation                          Yes____      No____
   YYYYY Corporation                          Yes____      No____
   ZZZZZ Corporation                          Yes____      No____
   If YES to any of the above, please explain the relationship and whether there have been any problems:
   ____________________________________________________________________________________________
   ___________________________________________________________________________________________
    ___________________________________________________________________________________________
36. Have you ever had any problem with an insurance company paying a claim?       Yes____    No____
   If YES, how was it resolved: ___________________________________________________________________
   ___________________________________________________________________________________________
   ____________________________________________________________________________________________
37. If YES, were you satisfied with how it was resolved?                            Yes____ No____

38. Have you or anyone close to you, ever been denied insurance coverage?           Yes____ No____

39. Have you ever had any dealings with an insurance claims adjuster?               Yes____ No____

40. If YES, were you treated fairly by the insurance claims adjuster?               Yes____ No____
   Please explain your feelings about how you were treated: ___________________________________________
   ____________________________________________________________________________________________

41. Have you or anyone close to you ever had insurance coverage canceled?          Yes____ No____
   If YES, when and why did that occur? ___________________________________________________________
   ___________________________________________________________________________________________
   ____________________________________________________________________________________________
42. Have you or anyone close to you ever been involved in a dispute with (or sued) an insurance company?
   Yes, I have _____    Yes, someone close to me has _____      No _____
   If YES, please explain which companies and when: ________________________________________________
   ____________________________________________________________________________________________
43. Have you or anyone close to you ever worked for an insurance company?           Yes____ No____
   Yes, I have _____    Yes, someone close to me has _____      No _____
   If YES, please explain which companies and when: ______________________________________________
   ____________________________________________________________________________________________
44. Have you or anyone close to you ever had any experience handling insurance claims?   Yes____   No____
   Yes, I have _____    Yes, someone close to me has _____      No _____
   If YES, please explain the type of experience and when: ____________________________________________
   ____________________________________________________________________________________________
45. What complaints or annoyances, if any, do you have about insurance companies?
   ___________________________________________________________________________________________
   ____________________________________________________________________________________________

                                                  Page 5 of 9
46. Do you have relatives or close friends who are judges, attorneys or court personnel?
   If YES, please list their names and their relationship to you: ________________________________________
   ____________________________________________________________________________________________
47. Do you feel that money damages awarded in lawsuits are (check one):
   ____ Often too large ____ Sometimes too large
   ____ Often too low ____ Sometimes too low
   ____ About right     ____ Other (specify): _______________________________________________________

   TO WHAT EXTENT DO YOU AGREE OR DISAGREE WITH THE FOLLOWING STATEMENTS
   (CHECK ONE BOX FOR EACH STATEMENT):
                                                                   Strongly      Agree       Disagree    Strongly
                                                                    Agree                                Disagree
   48. Insurance companies often treat their policyholders
       unfairly.
   49. I trust insurance companies to do the right thing most
       of the time.
   50. Most insurance companies take too long to pay claims.
   51. If an insurance company is being sued it’s probably
       because they did something wrong.
   52. Insurance companies will do almost anything to avoid
       paying claims, even if it means “bending” a law.
   53. Most people have to fight with their insurance
       company to get a claim paid.
   54. Punitive damages are the best way to punish
       corporations for past behavior.
   55. Punitive damages are the best way to deter companies
       from bad behavior in the future.
   56. An important function of juries in America is to send
       messages to corporations and individuals to improve
       their behavior.
   57. People who file lawsuits are simply trying to place
       responsibility where it belongs.
   58. One person can have an impact on government policy
       and decisions.
   59. It’s always possible to determine who’s at fault in any
       given situation.
   60. Luck has a lot to do with where someone gets in life.

61. What is your general attitude toward awarding punitive damages?
   ___________________________________________________________________________________________
   ____________________________________________________________________________________________
62. Do you have ethical, religious, political, or other beliefs that may prevent you from serving as a juror?
   If YES, please explain: ________________________________________________________________________
   ____________________________________________________________________________________________



                                                    Page 6 of 9
63. Do you have ethical, religious, political, or other beliefs that may prevent you from awarding money
    damages?
    If YES, please explain: ________________________________________________________________________
   ____________________________________________________________________________________________
64. Describe any problems (vision, hearing, language difficulty, medical problems, or other) that may affect
    your jury service _____________________________________________________________________________
    ___________________________________________________________________________________________
65. Do you believe there is anything else that was not covered in this questionnaire that would prevent you from
    being able to sit as a juror on this case and act fairly and impartially?                 Yes____ No____
    If YES, please explain: ________________________________________________________________________
    ____________________________________________________________________________________________

66. Is there anything else you feel is important for the Court to know about you?  Yes____ No____
    If YES, please explain_________________________________________________________________________
   ____________________________________________________________________________________________
   ____________________________________________________________________________________________
67. Do you know any of the following lawyers? XXXXXXX, XXXXXXX, XXXXXXX            Yes____ No____
    If YES, please explain:________________________________________________________________________
    ____________________________________________________________________________________________

68. The following section includes a list of potential parties and witnesses in this case. Please indicate if you are
    acquainted with any of the following individuals, If yes for any, describe your relationship below.
    Xxxxxxx Yes ___ No ____             Xxxxxxx                  Yes ___ No ____
    Xxxxxxx Yes ___ No ____             Xxxxxxx                  Yes ___ No ____
    Xxxxxxx Yes ___ No ____             Xxxxxxx                  Yes ___ No ____
    Xxxxxxx Yes ___ No ____             Xxxxxxx                  Yes ___ No ____
    Xxxxxxx Yes ___ No ____             Xxxxxxx                  Yes ___ No ____
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________


    Thank you for helping us select a fair and impartial jury for this case. Please do not attempt any research or
    discussion on this matter. To ensure fairness to all parties, it is essential that jurors make their decision based on
    evidence they hear in court, only.
    I affirm under penalty of law that I answered truthfully and completely all questions in this questionnaire
    and understand that it is a violation of law not to do so.


    _____________________________
    Print Name (First and Last)

    _____________________________
    Signature

    ____________________________
    Date




                                                        Page 7 of 9
EXTRA PAGE for ADDITIONAL RESPONSES




             Page 8 of 9

								
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