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FORENSIC STATISTICS & LITIGATION SUPPORT

Phone: (702) 263-8044

Fax: (702) 263-8740


 

  


Personal Injury:Adult - Questionnaire

Forecasting an individual's expected lifetime wage loss and expressing them in present value are the key issues we address in personal injury cases.

We use a large database called the Current Population Survey (CPS) to relate earnings to age, occupation, education, ethnicity and disability status. This allows us to estimate earning capacity for individuals with little or no earnings history- children, housewives, and those relocating or changing careers.

Lost Earnings Evaluation: Personal Injury (Adult)

Plaintiff's Information

First Name: Last Name:

Street Address:

City: State: Zip Code:

Phone: (i.e. 702-263-8044)

Email:

Demographic Information

Date of Birth: (i.e. YYYY/MM/DD)

Race: Citizenship:

If Others, please specify:

Gender: Marital Status:

Highest grade of school completed/degrees received:

Children?

Date of injury: (i.e. YYYY/MM/DD)

Last Day Working: (i.e. YYYY/MM/DD)

Additional Information

Prognosis for Recovery

What is the condition of victim? Current? Long-Term Prognosis?

Has the victim retuned to work?

Are there any pre-existing medical conditions or disabilities?

Does the medical conditions or disabilities restrict any type or amount of work the victim can perform?

Has the victim started any vocational training and or rehabilitation?

Post injury occupation:

Other Considerations

Hours of free time:

Hourly cost of replacement help: Past and or expected future medical expenses:

Lost quality of life:

Attachment1:

Attachment2:

Attachment3:

Attachment4:

Attachment5:

Please Provide the following:

1. If disabled, evidence (i.e. doctor's report, Social Security Disability Rating, etc)

2. Copy of complaint

3. Relevant expert reports

4. Copy of relevant depositions

5. Earnings & benefits history (pre & post injury)