Personal Injury Evaluation Form
Please answer as many questions as possible. ATTORNEY INFORMATION: Name ________________________________________________________________________________________________________________________ Name of Firm__________________________________________________________________________________________________________________ Street ________________________________________________________________________________________________________________________ City, State & Zip Code _______________________________________________________________________________________ ____________________ Telephone & FAX Number ________________________________________________________________________________________________________ CASE INFORMATION: Case Name or Title _______________________________________________________________________________________________________________ Subject's Name ______________________________________________________________________________________ Date of Birth ____/____/____ Gender: ¨ M ¨ F Number of Children: __________ Race (for actuarial purposes only) ______________________________________________ Marital Status: ¨ single ¨ married ¨ separated/divorced Date of Accident ____/____/____ Pre-injury Occupation ____________________________________________________________________________________________________________ Pre-injury Employer ______________________________________________________________________________________________________________ Post-injury Occupation ___________________________________________________________________________________________________________ Post-injury Employer _____________________________________________________________________________________________________________ Description of injury's effect on subject's earning capacity:_______________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Description of household duties, hobbies, and extracurricular activities: ____________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________
Personal Injury Evaluation Form Page 2 Has this accident impaired the performance of any of the above? ___________________________________ ______________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ * Please explain in detail all items requested on separate sheet if necessary.
EARNING HISTORY: Please list the subject's income beginning 4 years prior to injury.
Pre-Injury Income |
Post-Injury Income |
||
Year |
Amount |
Year |
Amount |
OTHER
INFORMATION (Please describe
the subject's education, pre- and post-injury career plans,
relevant work experience, and any other pertinent
factors):______________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe employer paid fringe
benefits (health insurance, pension, etc. include amounts if
known) for both pre-injury and
post injury employment:
_________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Personal Injury Evaluation Form Page 3
Description of medical expenses and amounts: To date medical expenses $________________________________________________________________ Future expected medical expenses (include year(s) expected and amounts): ____________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ PLEASE CHECK: ¨ Plaintiff ¨ Defense ¨ Enclosed is a check for $500 payable to Lawyer's Valuation & Structured Settlements or ¨ Additional Original Bound Reports ordered now @ 15.00 each Quantity __________
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