Case Evaluation form

Case Evaluation Research Services Form

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	Standard Service : $190

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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

Geographic Region:

Search for:

	Plaintiff Verdicts
	Defense Verdicts
	Settlements
	Arbitrations
	Mediations

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Disclaimer: Jury Verdict Research^® Services are designed to provide attorneys and insurance professionals with accurate and authoritative information. They are sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services. If legal advice or other expert assistance is required, the services of a competent professional person should be sought. "From a Declaration of Principles jointly adopted by a Committee of the American Bar Association and a Committee of Publishers and Associations."

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