Form - Personal Injury Evaluation Form

Legal Economic Evaluations
437 Century Park Drive
Suite A
Yuba City, CA 95991
Phone: (800) 221-6826
Fax: (530) 671-0337

Personal Injury Evaluation Form

Attorney Information

Name:

Firm:

Street Address:

City:

State:

ZIP:

Phone:

FAX:

Case Information

Case Name or Title:

Date of Injury:

Email Address:

Name of Injured Person:

Date of Birth:

Gender:
Male Female

Pre-Injury Income Information

Employer:

Title:

Year 1:	Salary:
Year 2:	Salary:
Year 3:	Salary:
Year 4:	Salary:

	Profit Sharing
	Health Insurance
	Retirement
	Life Insurance
	Other:

Post-Injury Income Information

Employer:

Title:

Date Migrating Income Starts:

Year 1:	Salary:
Year 2:	Salary:
Year 3:	Salary:
Year 4:	Salary:

	Profit Sharing
	Health Insurance
	Retirement
	Life Insurance
	Other:

Medical Information

To-Date Expenses:

Future Expenses Year:
$

Treatment:

Additional Information

Payment Information

Please submit a check for $750 payable to Legal Economic Evaluations
Addition bound reports are $25 each.

We make no attempt to independently verify your data.
The accuracy of our report depends upon the validity and completeness
of the data submitted with this form.