Personal Injury Case Valuation Worksheet
This worksheet is intended to be used as a starting place for you to review the potential value of your personal injury case with your attorney. We suggest that you PRINT THIS FORM, then mail it, fax it, or take it with you to your attorney as the beginning place for his or her discussions with you.
In order to be certain that this document is privileged, and therefore unavailable to the defendant(s) or potential defendant(s) in your case, you should discuss your intention to complete this form with your attorney before completing it. Under certain circumstances, such documents can become discoverable and the opposing parties in your lawsuit can obtain copies of them.
Basic Information:
First Name:_____________________________________________
Last Name:_____________________________________________
E-mail Address:_________________________________________
FAX No.:_______________________________________________
Home Phone No.:_________________________________________
Work Phone No.:_________________________________________
Address:________________________________________________
City:___________________________________________________
State:_________________________ Zip Code:________________
Type of accident or incident giving rise to injuries:
____ Motor Vehicle Accident
____ Medical Malpractice
____ Product Related
____ Pharmaceutical Product
____ Other - Please Describe Briefly:
Additional Comments:
PLEASE COMPLETE THE FOLLOWING INDICATING THE TOTAL AMOUNT OF DAMAGE YOU HAVE SUFFERED OR ARE REASONABLY CERTAIN TO SUFFER IN THE FUTURE FOR EACH CATEGORY
1) Medical Expenses
|
AMOUNT
INCURRED
OR
SUFFERED
TO DATE |
AMOUNT
REASONABLY
CERTAIN TO
INCUR
OR
SUFFER
IN THE
FUTURE |
____________ ____________ a) In-patient Hospital Expenses
____________ ____________ b) Out-patient Hospital Expenses
____________ ____________ c) Doctor Expenses
____________ ____________ d) Physical Therapy Expenses
____________ ____________ e) Other Therapy (e.g. speech therapy, vocational therapy etc.)
____________ ____________ f) Prosthesis
____________ ____________ g) Physical Aid & Equipment (e.g., crutches, wheel chairs, canes, braces, neck collars, etc.)
____________ ____________ h) Rehabilitation
____________ ____________ i) Psychiatry/Psychology
____________ ____________ j) X-ray
____________ ____________ k) Laboratory work
____________ ____________ l) Diagnostic Procedures (e.g., MRI, C-T Scan, etc.)
____________ ____________ m) Other - Describe:
2) Loss of Earnings, Earnings Power, and Earnings Capacity
|
AMOUNT
INCURRED
OR
SUFFERED
TO DATE |
AMOUNT
REASONABLY
CERTAIN TO
INCUR
OR
SUFFER
IN THE
FUTURE |
____________ ____________ a) Loss of wages
____________ ____________ b) Commissions
____________ ____________ c) Bonuses
____________ ____________ d) Tips/Gratuities
____________ ____________ e) Vacation Time
____________ ____________ f) Sick Leave
____________ ____________ g) Value of Lost/Delayed Promotions
____________ ____________ h) Value of Lost/Delayed Pay Raises
____________ ____________ i) Lost Retirement Credits
____________ ____________ j) Value of Lost Insurance & Other Benefits
3) Loss of Household & Family Services
Please check each item you have been unable to perform for some period of time since your injury and each which you are reasonably certain to be unable to perform for at least some period of time in the future:
|
UNABLE
TO PERFORM
FOR AT
LEAST SOME
PERIOD OF
TIME SINCE
YOUR
INJURY |
UNABLE
TO PERFORM
FOR AT
LEAST SOME
PERIOD OF
TIME IN THE
FUTURE |
____________ ____________ (1) House work
____________ ____________ (3) Cooking
____________ ____________ (4) General Maintenance
____________ ____________ (5) Child Care
____________ ____________ (6) Other - Describe:
4) Other Economic Losses - Describe type & value:
5) Noneconomic Losses - Pain, Suffering and Emotional Distress
Indicate each type of damage which you have suffered or are reasonably certain to suffer in the future as a result of your injury:
|
AMOUNT
INCURRED
OR
SUFFERED
TO DATE |
AMOUNT
REASONABLY
CERTAIN TO
Incur
OR
SUFFER
IN THE
FUTURE |
____________ ____________ (1) Pain
____________ ____________ (2) Suffering
____________ ____________ (3) Fright
____________ ____________ (4) Nervousness
____________ ____________ (5) Worry
____________ ____________ (6) Distress
____________ ____________ (7) Grief
____________ ____________ (8) Embarrassment
____________ ____________ (9) Humiliation
____________ ____________ (10) Mortification
____________ ____________ (11) Indignity
____________ ____________ (12) Apprehension
____________ ____________ (13) Fear
____________ ____________ (14) Terror
____________ ____________ (15) Ordeal
____________ ____________ (16) Phobia
____________ ____________ (17) Neuroses
____________ ____________ (18) Loss of Enjoyment of Life
____________ ____________ (19) Sleep Difficulties
____________ ____________ (20) Disfigurement
____________ ____________ (21) Scarring
____________ ____________ (22) Other Describe:
6) Miscellaneous Damages/Injuries
a) Have you suffered or are you reasonably likely to suffer in the future, an increased susceptibility to disease or injury?
____ Yes ____ No ____ Unknown
b) Have you suffered or are you reasonably likely to suffer in the future, a reduction in your vitality, strength, or endurance?
____ Yes ____ No ____ Unknown
c) Have you suffered a reduction in your life expectancy?
____ Yes ____ No ____ Unknown
d) Have you suffered an aggravation of an injury which existed prior to the injury which is the subject of this dispute?
____ Yes ____ No ____ Unknown
e) Have you or your spouse suffered a loss of consortium, that is, a loss of love, companionship comfort, affection, society, sexual relations, ability to have children, solace, support, sexual relations, solace, support, services, moral support, or physical assistance as a result of you or your spouse being injured?
____ Yes ____ No ____ Unknown
f) Have you suffered any other injury or damage not otherwise listed here as a result of the physical injury which is the subject of this dispute?
____ Yes ____ No ____ Unknown
If "yes", please describe:
|