Personal Injury Case Evaluation Service Form

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	Standard Service

	24-Hour Service:(additional $100; order must be received by 3pm ET.)

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1. Case Caption/Docket#:
2. Date of Incident:
3. Probable Location of Trial:	State County
4. Is Liability Admitted?	Yes	No
5. Brief Description of the Liability Situation:
6. Plaintiff and Defendant(s) (Complete both A & B)

Part A: Plaintiff or Decedent Characteristics
Age at Incident or Death:		Sex:
Occupation:
Marital Status:
Number of Children:
Children's Ages (ex. 8,12, etc.):
Criminal Record Admissible in Evidence:	Yes		No
Alcohol Use Related to Incident:	Yes		No
History of Alcohol or Drug Abuse Admissible as Evidence:	Yes		No
Obesity:	Yes		No
Prior Physical and/or Mental Disability:	Yes		No
Racial Minority (Specify race):
Death Unrelated to Incident:	Yes		No

Part B: Defendant(s) Characteristics

Number of Individual Defendants:

Ages:
Sex:

Number of Business or Government Defendants:

Type of Business or Government Agency:

Alcohol Use Related to Incident:

Yes

Prior Physical and/or Mental Disability:

Yes

Racial Minority (Specify race):

Death Unrelated to Incident:

Yes

Suit within Family:

Yes

Relationship:

Cross Complaint (Describe):


7. Medical Expenses and Wage Loss (Include medical expenses even if paid by third party) Note: In case of death, skip to section 8D.
Medical Expenses:			Lost Earnings:
To Probable Date of Trial Total	$		To Probable Date of Trial Total	$
Is Total Contested?	Yes	No	Is Total Contested?	Yes	No
After Trial Total	$		After Trial Total	$
Is Total Contested?	Yes	No	Is Total Contested?	Yes	No

8. Injuries (Complete A, B and C; or D) Note: Can evaluate up to five injuries.
Part A. Injuries Not Resulting in Death (Including actual injury and surgical/medical procedure)		Part B. Permanent Impairment (Refer to American Medical Association guidelines) Note: Percent must be by body as a whole impairment.
Most Serious Injury:		%
Second Most Serious Injury:		%
Third Most Serious Injury:		%
Fourth Most Serious Injury:		%
Fifth Most Serious Injury:		%
Additional Injury Information:
	Reflex Sympathetic Dystrophe
	Intentional Acts

Part C. Scarring
Body Part:	Surgical:	Yes	No
Body Part:	Surgical:	Yes	No
Body Part:	Surgical:	Yes	No
Body Part:	Surgical:	Yes	No
Body Part:	Surgical:	Yes	No

	Part D. Death — Decedent Information Note: Once section 8D is complete, skip to section 10 in cases of death.
	Number of Dependents:		Conscious Survival Time:
	Dependents' Ages:		Unconscious Survival Time:
	Annual Earnings at Time of Death:		Medical Expenses (Excluding funeral expenses):

9. Injury Contested by Defendant(s)? (Choose up to two)

Denial of Some Injuries:

Yes

Impairment Contested:

Yes

Injury Unrelated to Incident:

Yes

No Injury Sustained:

Yes

10. Witnesses

Disinterested Eyewitness(es) for Plaintiff:

Yes

Disinterested Eyewitness(es) for Defendant:

Yes

Expert Witnesses:

Expert Specialty:

Plaintiff (P)
or Defense (D)

11. Loss of Services Evaluation ($50 Additional)

Relationship to Plaintiff:

Age of Claimant:

Occupation of Claimant:

Marital Status:

Number of Children:

Comments:

12. VerdictFinder (an additonal $135 ... You Save $50 of regular price)

Case Caption/Docket#:

Time Frame (date range):

Plaintiff Age:

Plaintiff Sex:

Male

Female

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Search for:

	Plaintiff Verdicts
	Defense Verdicts
	Settlements
	Arbitrations
	Mediations

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