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Data Sheets

 
 
1)
Name of Attorney:
Firm Name:
Address:
Telephone: Fax:
Representation:
2)
Type of Case: If Other:
3)
Law to use for economic damages: If Other:
4)
Name of Case:
5)
Name of Victim:
6)
Address:
7)
Date of Birth: (mm/dd/yyyy)
8)
Date of Incident: (mm/dd/yyyy)
9)
Date of Death (if applicable):
(mm/dd/yyyy)
10)
Brief Description of Incident:
11)
Dependents:
  Name Relationship Date of Birth
Spouse (mm/dd/yyyy)
Children
 
 
12)
Educational Attainment/Training History:
13)
Occupation/Job Title:
14)
Dates of Employment:
15)
Pay Rate at time of incident:
16)
Historic changes in rate of pay up to the present (if available, please provide wage contracts, bargaining agreements, etc.):
  Date Pay Rate   Date Pay Rate
1 4
2 5
3 6
17)
History of earnings:
For the years prior to the incident:
  Year Earnings Comments
1
2
3
       
For the years since the incident:
  Year Earnings Comments
1
2
3
18)
For cases involving partial disability, indicate the projected current occupational capabilities and the expected current level of earning capacity for the victim:*
* It may be necessary to obtain a vocational expert's opinion of residual earning capacity for partial disability cases. Our offices can recommend a vocational expert if you should need to use one.
19)
Cost to Employer to provide Fringe Benefits:
20)
Description of Fringe Benefits:
21)
Anticipated Retirement Age:
22)
Special Career Plans:
 
23)
For cases involving death of a Minor, please provide a separate narrative that discloses the educational backgrounds, employment histories, and earnings levels for the parents, siblings and other relatives.
24)
Description of household services provided prior to the incident which the victim is no longer able to provide:
25)
Estimated average time per week spent by victim on the above-described lost household services:
26)
For cases involving ongoing medical, institutional, nursing or personal care, describe the anticipated annual costs for this care below:*
*It may be necessary to obtain a nursing expert's opinion of annual medical care requirements for the victim. Our offices can recommend a nursing expert if you should need to use one.
 
 
 
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