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Hill Economics

valuations of individuals, events, property, and policy

  • CURRICULUM VITAE
  • VALUATIONS
  • PRESS

Questionnaire for determination of loss associated with an individual's injury

If possible, this form should be completed by the individual's family or someone familiar with deceased person's situation at the time of death. Ideally, this form would be completed with the assistance of the case attorneys or their support staff. Please answer all appropriate questions. If you do not understand a question, contact me.

"*" indicates required fields

Parties to lawsuit

Injured individual

Provide facts about the injured individual
Name
MM slash DD slash YYYY
MM slash DD slash YYYY
Has a life care plan been developed for the injured individual?
Has the injured individual been evaluated by a vocational analyst?

Family

If relevant, provide names and birth dates for spouse and children below age 18 living with the injured individual. Disabled children above age 17 depending on injured for care should be included.
Spouse's name
MM slash DD slash YYYY
Dependent 1 name
MM slash DD slash YYYY
Dependent 2 name
MM slash DD slash YYYY
Dependent 3 name
MM slash DD slash YYYY
Dependent 4 name
MM slash DD slash YYYY
Dependent 5 name
MM slash DD slash YYYY
Dependent 6 name
MM slash DD slash YYYY
Dependent 7 name
MM slash DD slash YYYY
Dependent 8 name
MM slash DD slash YYYY
Dependent 9 name
MM slash DD slash YYYY
Dependent 10 name
MM slash DD slash YYYY

Pre-injury employment

Provide information about pay and benefits prior to injury
MM slash DD slash YYYY
life insurance:
individual health insurance
family health insurance
long-term disability insurance
short-term disability insurance
employer 401k match
pension plan
bonus plan
stock option
paid vacation

Post-injury employment

Leave blank if unemployed following injury. If reemployed, provide information about pay and benefits from employment.
MM slash DD slash YYYY
life insurance:
individual health insurance
family health insurance
long-term disability insurance
short-term disability insurance
employer 401k match
pension plan
bonus plan
paid vacation

Pre-injury household services

Provide hours of weekly household services performed prior to injury.

Post-injury household services

Provide hours of weekly household services performed following injury.

Legal counsel

Provide contact information for legal counsel for the injured individual.
Address*
Attorney
Paralegal / alternate contact

Additional records for the injured invidual

Given the uniqueness of your client's situation, we will likely need additional information to estimation of economic damages. Please upload relevant deposition transcripts, tax returns (ideally spanning a 10-year period, but certainly the most recent return), employer handbooks detailing benefits, reports of doctors, rehabilitation specialists or vocational analysts, and information that details compensation and benefits.
Drop files here or
Max. file size: 2 GB.
    This field is for validation purposes and should be left unchanged.

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