Wrongful Death Case Valuation Worksheet
This worksheet is intended to be used as a starting place for you to review the potential value of your wrongful death 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:
Relationship of deceased party to you:
____ Husband
____ Wife
____ Child
____ Parent
____ Other
Additional Comments:
PLEASE COMPLETE THE FOLLOWING FOR YOUR WRONGFUL DEATH CASE
1) Age of decedent at time of death: _______
2) Your age at time of decedent's death: _______
3) Ages of decedent's children at time of decedent's death: __________
4) Annual income of decedent at time of death: ____________
5) Annual value of benefits (e.g., health insurance, retirement contributions, etc.) earned by decedent at time of death: ________
6) Did you loss any benefits such as insurance as a result of decedent's death? _____Yes ____No
If so, what is the annual value of those benefits? _____________
7) Did you suffer a reduction in the amount of retirement benefits you will receive as a result of decedent's death? ____ Yes ____ No
If so, what is the annual value of those benefits? _____________
8) Did the deceased provide you or your family with any of the following types of assistance:
YES NO
______ ______ a) Housework
______ ______ b) Gardening
______ ______ c) Cooking
______ ______ d) Child care
______ ______ e) General household maintenance
______ ______ f) Automobile maintenance or repair
______ ______ g) Laundry
______ ______ h) Shopping
______ ______ i) Driving
9) What was the value of all gifts which decedent gave to you each year at the time of death? _____________
10) What was the value of all gifts which decedent gave to others each year at the time of death? ___________
11) What was the total amount of expenses incurred for funeral and burial? _____________
12) What was the total amount of expenses incurred for medical care for decedent's last illness or injury? ________________
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