ATTORNEY INFORMATION GENERAL INFORMATION 
Attorney: Claimant’s Name: 
Law Firm: Claimant’s D.O.B. 
Address: Claimant’s Sex Male ..Female ..
Claimant’s Educational Level: 
Email: 
Phone # Fax # Spouse’s Name: 
PERTINENT DATES Spouse’s D.O.B. / / 
Date of Accident / / Dependent’s Names 
Date of Trial / / 
Deadline for Report / / Dependent’s D.O.B. / / 
Date of Arbitration/Mediation: / / / / 
FOR DEATH CASES TRIAL INFORMATION 
Date of Death / / Court: Parish/District: 
Amount decedent used for subsistence 
maintenance ($ or %). _______________ Judge ____________ Jury ..Bench ..
OCCUPATIONAL INFORMATION TYPE OF CASE – RULE OF LAW 
Occupation State Court ..Before Tax ..After Tax ..
Employer Diversity ..Before Tax ..After Tax ..
Work Hitch Hourly Wage: $_______ Jones Act/General Maritime ..
Annual Earnings Info CLAIMANT SPOUSE Other ..
Year of Injury $ $ 
Pre Injury $ $ OCCUPATIONAL DISABILITY 
$ $ T&P ..Partial ..Both ..
$ $ If partial, at what post-injury earning capacity? 
Post Injury $ $ If partial, beginning when? / / 
$ $ 
Self Employed? YES .. NO .. If yes, please provide Schedule C 
PERSONAL SERVICES ..FUTURE MEDICAL COSTS .. FRINGE CONTRIBUTIONS ..
Weekly Hours 
Precluded: ________ hrs/wk 
Please attach supporting data 
(Lifecare plan, future recurring medicals) 
$ or % of employer’s cost_____ 
(Please attach supporting data) 
Please provide additional information such as tax returns, W-2 Forms, ERISA benefit cost 
summaries, union documentation, vocational rehabilitation reports, life care plans, etc. 
Vocational Rehabilitation – Life Care Planning 
Rehab Psychology Associates of New Orleans, LLC .Tel:(504) 236-7766 
Rehab Psychology Associates of New Orleans can provide a number of forensic evaluations including: 
•Full vocational assessment to determine pre-and post-injury earning capacity 
•Comprehensive psychological evaluation to assess the emotional impact of accident, injury, or chronic pain on employability 
•Detailed Life Care Planning, including medical record review, in-home evaluation and detailed assessment of future 
medical costs 
1710 Pine St. 
New Orleans, Louisiana 70118 
Tel : (504) 874-1097 
Fax: (504) 866-2100 
wwwwww..ffoorreennssiicceeccoonnoommiiccss..nneettForensic Economics Corporation 
Data Sheet 
Attorney: Claimant’s Name: 
Law Firm: Claimant’s D.O.B. 
Address: Claimant’s Sex Male ..Female ..
Claimant’s Educational Level: 
Email: 
Phone # Fax # Spouse’s Name: 
PERTINENT DATES Spouse’s D.O.B. / / 
Date of Accident / / Dependent’s Names 
Date of Trial / / 
Deadline for Report / / Dependent’s D.O.B. / / 
Date of Arbitration/Mediation: / / / / 
FOR DEATH CASES TRIAL INFORMATION 
Date of Death / / Court: Parish/District: 
Amount decedent used for subsistence 
maintenance ($ or %). _______________ Judge ____________ Jury ..Bench ..
OCCUPATIONAL INFORMATION TYPE OF CASE – RULE OF LAW 
Occupation State Court ..Before Tax ..After Tax ..
Employer Diversity ..Before Tax ..After Tax ..
Work Hitch Hourly Wage: $_______ Jones Act/General Maritime ..
Annual Earnings Info CLAIMANT SPOUSE Other ..
Year of Injury $ $ 
Pre Injury $ $ OCCUPATIONAL DISABILITY 
$ $ T&P ..Partial ..Both ..
$ $ If partial, at what post-injury earning capacity? 
Post Injury $ $ If partial, beginning when? / / 
$ $ 
Self Employed? YES .. NO .. If yes, please provide Schedule C 
PERSONAL SERVICES ..FUTURE MEDICAL COSTS .. FRINGE CONTRIBUTIONS ..
Weekly Hours 
Precluded: ________ hrs/wk 
Please attach supporting data 
(Lifecare plan, future recurring medicals) 
$ or % of employer’s cost_____ 
(Please attach supporting data) 
Please provide additional information such as tax returns, W-2 Forms, ERISA benefit cost 
summaries, union documentation, vocational rehabilitation reports, life care plans, etc. 
Vocational Rehabilitation – Life Care Planning 
Rehab Psychology Associates of New Orleans, LLC .Tel:(504) 236-7766 
Rehab Psychology Associates of New Orleans can provide a number of forensic evaluations including: 
•Full vocational assessment to determine pre-and post-injury earning capacity 
•Comprehensive psychological evaluation to assess the emotional impact of accident, injury, or chronic pain on employability 
•Detailed Life Care Planning, including medical record review, in-home evaluation and detailed assessment of future 
medical costs 
1710 Pine St. 
New Orleans, Louisiana 70118 
Tel : (504) 874-1097 
Fax: (504) 866-2100 
wwwwww..ffoorreennssiicceeccoonnoommiiccss..nneettForensic Economics Corporation 
Data Sheet