Wrongful Death Economic Loss Information Form

Decedent Information

First Name

Last Name

Address at time of death

Address 1

Address 2

City

State

Zip Code

Demographics

Gender

Male

Female

Non-binary

Marital Status

Single

Married

Divorced

Widowed

Separated

Domestic Partnership

Date of Birth

Date of Death

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

Dependents

Household

For each person living in the decedent's household at the time of death, please list the name, date of birth, and relationship to the decedent.

Full Name	Date of Birth	Relationship to Decedent

Other Dependents

For other dependent individuals (not living in the household), please list the name, date of birth, and relationship to the decedent.

Full Name	Date of Birth	Relationship to Decedent

Medical

Describe decedent's health prior to death, including known health issues or shortened life expectancy.

Describe any work missed due to health issues.

Education

Highest level of education completed

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 decedent.

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

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

Employment

Employment status at the time of death

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 death.

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

Please describe any overtime work, including wages and frequency.

Was work steady?

Annual wages and salary received

Year	Income	% 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 death.

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.

At what age was the decedent planning to retire?

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

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

Household Services

For each category of tasks below, indicate the frequency and extent to which the decedent engaged in these activities using the scale described below:

0 - Had no role in these tasks
1 - Occasionally performed these tasks
2 - Regularly performed these tasks
3 - Was primarily responsible for performing these tasks

Care of Dependent Family Members

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

0 - Had no role in these tasks

1 - Occasionally performed these tasks

2 - Regularly performed these tasks