Wrongful Termination Economic Loss Information Form

Instructions:
Unless otherwise indicated, all items on this form refer to the plaintiff.

This form can be:
1. completed electronically and then printed or saved to .pdf, or
2. printed first and completed by hand.

Send this form and supporting documents to forms@the-bradley-group.com.

Contact Information

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Email Address

Phone Number

Phone Type

Mobile

Home

Work

Other

Education

Pre-Termination

Highest level of education completed prior to termination

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 termination.

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

Post-Termination

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

Employment

Pre-Termination Employment

Employment status at the time of the incident

Full-time

Part-time

Contract

Temporary

Self-employed

Unemployed

Job title or position

Employer Name

Start date

Hourly wage or annual salary

Briefly describe work duties and responsibilities at date of termination.

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	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 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 termination, at what age was the plaintiff planning to retire?

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

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

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

Contract

Temporary

Self-employed

Unemployed

Not Applicable

Job title or position

Employer Name

Start date

Hourly wage or annual salary

Briefly describe of 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	Income	% 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 termination, at what age is the plaintiff planning to retire?

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

Describe job search efforts since termination, including applications submitted, interviews conducted, and any job offers received.

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:

Pre-Termination 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-Termination 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

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)