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Personal Injury Case Questionnaire

General Information

*Submitter's Name:

*Court:

State

*Outcome:

Federal

Plaintiff Verdict

Defense Verdict

Settlement

* Case Caption:

* State:	*County:	Federal District :
*Court Level:	Docket#:
Judge:
Date of: (MM/DD/YY)
Incident:	Filing :	*Date of Outcome:

Appeal Information

Appeal Filed?
(check if yes)

Appellate Docket#:

Date:

Appeal Filed by:

Plaintiff

Defense

Name of Party:

Plaintiff Award Breakdown (plaintiff verdicts and settlements must have $ amount)

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

Pain and Suffering:

Punitive Damages:

Past Medical:

Hedonic Damages:

Past Wage:

Attorney Fees:

Future Medical:

Property:

Future Wage:

Interest:

Other Compensatory:

Other Noncompensatory:

Loss of Services:

Brought by:		Child		Sibling
		Spouse		Parent/Guardian

Percentage of Negligence Assigned to Plaintiff:

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:

*Plaintiff Contentions: (against each defendant, if more than one)"

*Defense Contentions:

*Dispute of Plaintiff's Injuries? (Yes or 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 Admitted? (Yes or 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
	Eyewitness for Plaintiff
	Eyewitness for Defendant
	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:

* = Required Fields

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