Personal Injury Economic Loss Information Form

Contact Information

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Email Address

Phone Number

Phone Type

Mobile

Home

Work

Other

Demographics

Gender

Male

Female

Non-binary

Date of Birth

Marital Status

Single

Married

Divorced

Widowed

Separated

Domestic Partnership

Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Household

For each person living in the plaintiff's household, list the name, date of birth, and relationship to the plaintiff.

Full Name	Date of Birth	Relationship to Plaintiff

Medical

Current

Date of Incident

Describe the nature of the injury and limitations.

If another party is making a claim for lost earnings due to time spent caring for the plaintiff, provide details.

Future

If medical evidence indicates plaintiff's life expectancy has been reduced due to this injury, provide details.

Detail future medical expenses including current cost and number of years they will be incurred. Consider nursing home care, in-home nursing care, physician care, drugs, medical appliances, physical therapy, psychiatric therapy, and surgery. If a Life Care Planner is preparing a report, reference that here.

Education

Pre-Injury

Highest level of education completed prior to injury

High School

Some College

Associate's Degree

Bachelor's Degree

Master's Degree

Doctorate

Professional Degree

Other

List any licenses, training, or special skills held by the plaintiff at the time of the injury.

Detail any plans the plaintiff had to attain further educational degrees, licenses, or training at the time of the injury.

If the plaintiff was a minor or had yet to finish formal education at the time of the injury, list the education levels and occupations of the plaintiff's parents.

Post-Injury

Detail any education, training, or special skills the plaintiff has acquired since the date of injury, including the length and costs of all programs.

Employment

Pre-Injury Employment

Employment status at the time of the incident

Full-time

Part-time

Self-employed

Unemployed

Student

Retired

Job title or position

Employer Name

Start date

Hourly wage or annual salary

Brief description of work duties and responsibilities at date of injury.

List all advancements within the company, including promotions and raises (include title changes, raise amounts, and dates).

Describe any overtime work, including wages and frequency.

Was work steady?

Annual wages and salary received

Year	Annual Income	Percent of Year Employed

Note: Attach documentation supporting wages and salary received.

Benefits

Describe all benefits provided by the employer, or to which the employer contributed prior to the injury.

Life Insurance:

Individual Health Insurance:

Family Health Insurance:

Retirement Plan:

Investment Plan:

Bonus:

Stock Options:

Other:

Note: Attach copies of any I.R.A., 401K, Profit Sharing, or other benefit plans.

Prior to the injury, at what age was the plaintiff planning to retire?

What were the plaintiff's career trajectory expectations prior to injury (promotions, pay raises, etc.)?

List any out-of-the-ordinary expenses associated with this job.

Has the plaintiff been declared unable to work, or has a disability rating been provided by a doctor or rehabilitation specialist?

Note: Attach any documentation related to the previous question.

Post-Injury Employment

If the plaintiff has not been employed since the date of the injury, continue to the next section.

Current employment status

Full-time

Part-time

Self-employed

Unemployed

Disabled

Retired

Job title or position

Employer Name

Start date

Hourly wage or annual salary

Briefly describe work duties and responsibilities.

List all advancements within the company, including promotions and raises (include title changes, raise amounts, and dates).

Describe any overtime work, including wages and frequency.

Is work steady?

Annual wages and salary received:

Year	Annual Income	Percent of Year Employed

Note: Attach documentation supporting wages and salary received.

Benefits

Describe all benefits provided by the current employer, or to which the current employer contributes.

Life Insurance:

Individual Health Insurance:

Family Health Insurance:

Retirement Plan:

Investment Plan:

Bonus:

Stock Options:

Other:

Note: Attach copies of any I.R.A., 401K, Profit Sharing, or other benefit plans.

Given the injury, at what age is the plaintiff planning to retire?

List any out-of-the-ordinary expenses associated with this job.

Household Services

For each category of tasks below, indicate the injured party's ability to complete the listed tasks using a scale of 0-5, as described below:

0 - Injury has no impact on ability to complete task, or did not complete task prior to injury.
1 - Injury has a minor impact on ability to complete task.
2 - Injury has a moderate impact on ability to complete task.
3 - Injury has a major impact on ability to complete task.
4 - Injury completely prevents completion of these tasks.

Care of Dependent Family Members

dressing, bathing, feeding, supervising, or transporting to and from events (includes children and adults)

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Pet Care

feeding, grooming, walking, picking up after, or otherwise caring for household pets

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Indoor Housework

vacuuming, sweeping, mopping, dusting, making beds, emptying trash, washing clothes, ironing, folding and putting laundry away, putting groceries away

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Meal Preparation and Cleanup

food preparation, cooking, serving, setting & clearing a table, washing dishes, loading & unloading a dishwasher, cleaning the kitchen

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Home/Yard Maintenance

painting, house repairs, gardening, mowing, trimming, edging, weeding

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Vehicle Maintenance

car washing, vacuuming, arranging appointments for maintenance & repair, taking vehicles to appointments

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Errands

shopping for groceries and other household items, disposing of trash, yard waste, etc. and other travel to complete tasks not included in other categories

0 - No impact

1 - Minor impact

2 - Moderate impact

3 - Major impact

4 - Completely prevents

Other

Provide any additional pertinent information which may have some bearing on past or future income or expenses.

Litigation

Matter No. (for law firm internal use only)

Date of Next Settlement Negotiation

Date of Trial

Location of Trial

Defendant

Name of firm of opposing counsel

Name and firm of opposing counsel's economist

Document Attachments

When submitting this form please attach any supporting documents, which may include:

Medical Documents:

☐ Life Care Plan (if available)
☐ Medical bills and expenses
☐ Future treatment plans

Pre-Injury Employment Documents:

☐ Tax returns (last 5 years prior to injury)
☐ Pay stubs
☐ Forms W-2
☐ I.R.A.
☐ 401K
☐ Profit-sharing Plan
☐ Employment contracts
☐ Benefits information / Statement of Benefits

Post-Injury Employment Documents:

☐ Tax returns
☐ Pay stubs
☐ Forms W-2
☐ I.R.A.
☐ 401K
☐ Profit-sharing Plan
☐ Employment contracts
☐ Benefits information / Statement of Benefits

Filer

Information about the person completing this form (either the plaintiff or an authorized representative on the plaintiff's behalf).

Filer's Full Name

Date Submitted

Filer's Phone Number

Filer's Email Address

Relationship to Plaintiff (if not self)