Attorney Information

Attorney

E-mail Address

Law Firm

 Postal Address

Phone

Fax

Pertinent Dates

Date of Accident

Date of Trial

Deadline For Report

Date of Arbitration/Mediation

General Information

Claimant's Name

Claimant's D.O.B

Claimant's Sex

Claimant's Race

Claimant's Educational Level

Spouse's Name

Spouse's Date Of Birth

List Dependents and
Dates Of Birth 

For Death Cases

Date of Death

Amount Used For Subsistence  Maintenance ($or%)

Occupational Information

Occupation

Employer

Work Hitch

Hourly Wage ($)

Please list Annual Earnings Pre and  Post Injury by Year

Self Employed?
If so supply Schedule C.

Trial Information

Court

Parish/District

Judge,Jury or Bench

Type of Case-Rule of Law

Please Indicate Which Apply

State Court (After or Before Tax)

Culver II

Diversity (After of Before Tax)

Other

Jones Act/General Maritime

Occupational Disability

T&P

Yes

No

Partial

Yes

No

Both

Yes

No

If partial, at what earning capacity?  Beginning when?

Loss of Capacity To Enjoy Life?

Yes

No

Please List Applicable Personal Services (Precluded Hrs/Wk)

i.e. vacuuming, dusting, cooking, ironing,gardening,yard maintenance,transportation, appliance repair, auto maintenance.

Please List Future Medical Costs

One Time Cost, Recurring Costs including physicians, medications, nurses,assistants,transportation, x-rays, lab costs, equipment, facility.

Fringe Contributions: Please Indicate Either $ or % Employer's Cost

Such as: Pension, Retirement, 401k, Medical Insurance, Hospitalization, Thrift Plan, Savings Plan, ESOP, Life Insurance, Meals and Lodging.

Additional Information

Please provide additional information such as tax returns, W-2 forms, ERISA benefit cost structures, vocational rehab reports, life care plans, etc., that contain relevant information.

Additional Comments