Personal Injury Case Questionnaire

Personal Injury Case Questionnaire

General Information

Name:

*Court:

State

*Outcome:

Federal

Plaintiff Verdict

Settlement

Defense Verdict

Settlement at Mediation

Plaintiff Judgment

Arbitration

Defense Judgment

Type of Attorney Submitting Case:

Plaintiff

Defendant

	*Case Caption:

	*State:		*County:		Federal District:
	*State:		(state level cases)		(state level cases)
	*Court Level:		Docket#
	Judge:			Venue Changed? (check if yes)	Prior Court:
	Date of: (MM/DD/YY)
	Incident:		Filing:		*Outcome:
	If Settlement case, indicate when settled (check one):
		before filing		after filing		after trial

Appeal Information

Appeal Filed?
(check if yes)

Appellate Docket#:

Date:

Appeal Filed by:

Plaintiff

Defense

Name of Party:

Plaintiff Award Breakdown

*Total Award: (should equal sum of bolded fields below)

$

Compensatory Total:

$

Punitive Damages:

$

Pain and Suffering:

$

Hedonic Damages:

$

Past Medical:

$

Attorney Fees:

$

Past Wage:

$

Property:

$

Future Medical:

$

Interest:

$

Future Wage:

$

Other:

$

Other:

$

Loss of Services:

$

Brought by:		Child		Sibling
		Spouse		Parent/Guardian

Comparative Percentage of Negligence:

%

Amount of Award After Judge's Reduction:

$

	*Brief Case Summary

*Injury

Injuries: (be specific)

Location of: (be specific)

Permanent Impairment:

Permanent Scarring:

Permanent Pain:

Permanent Limited Motion:

Permanent Weakness:

Internal Fixation:

Inability to Return to Former Occupation:		Yes		No		Percent of Whole Body Impairment:	%
Injury to Dominant Hand or Arm:		Yes		No		Length of Treatment:

Contentions/Liability

Past Medical Expense Claimed:

$

Past Wage Loss Claimed :

$

Future Medical Expense Claimed:

$

Future Wage Loss Claimed:

$

Final Demand:

$

Final Offer:

$

Future Wage Loss Claim By Plaintiff Economist:

$

Future Wage Loss Claim By Defense Economist:

$

*Plaintiff Contentions:

*Defense Contentions:

Dispute of Plaintiff's Injuries? (check)*		Yes		No
If yes, check reason(s) for dispute:		Denial of All Injuries				Exaggeration of Injuries
		Denial of Some Injuries				Impairment Contested
		Injury Unrelated to Incident

*Liability: (cause of litigation)

*Liability Admitted?

Yes

No

Plaintiff Information

Defendant Information

	*Sex	Age	Race	Occupation
Pltf 1
Pltf 2
Pltf 3
Pltf 4

	*Sex	Age	Race	Occupation	Org. Type
Def 1
Def 2
Def 3
Def 4

Pltf/Def. #:

Insurance:

Policy Limits:

	Attorney Information
	*Plaintiff Attorney(s) (name, firm, address, phone & fax):

	*Defense Attorney(s) (name, firm, address, phone & fax):

	Witness Information
	Plaintiff Expert Witness(s) (name, expertise, address, phone & fax):

	Defense Expert Witness(s) (name, expertise, address, phone & fax):

Additional Facts (check if claimed)

	Plaintiff with Criminal Record
	Defendant with Criminal Record
	Obese Plaintiff
	Plaintiff Under Influence of Alcohol
	Defendant Under Influence of Alcohol
	Plaintiff Under Influence of Drugs
	Defendant Under Influence of Drugs
	Heart Failure as a Defense
	Blackout as a Defense
	Class Action
	Consolidated Case

Bifurcated Trial

Plaintiff Smoker

Plaintiff with Disability

Defendant with Disability

Misrepresentation of Material Facts

Plaintiff Death Unrelated to Incident

Defendant Death Unrelated to Incident

High/Low Agreement?

High Amount	Low Amount:
$	$

Briefly Explain any boxes checked:

Death Cases Only

Decedent's sex:

Age:

Race:

Occupation:

Number of minor children:		Number of adult children:			Spouse?		Yes
Amount of conscious survival time:			Amount of unconscious survival time		Spouse?		No

Funeral Expenses:

$

Other Expenses:

$

Annual salary at time of death:

$

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