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Client Input

Submitting this form starts the process of obtaining your damages calculation. If desired, you can submit the payment and administration information first, or you can submit the entire form all at once. Ultimately, all information must be completed for Fulcrum to perform its work.

Section 1: Your Contact Information

Client Contact:

Your name
e-mail Address
Company Name
Physical Address
Phone Number Primary: Alternate:
Position  

Existing Clients Only:

Account Number

Case Name

Plaintiff Name(s)
Defendant Names(s)
On whose behalf is Fulcrum's work being prepared
Type of Case

Contact Me Before Starting:

I would like to be contacted before starting to answer questions regarding the applicability of this process to my situation.  (Describe concerns below)
 

Payment:

Payment will be made to Fulcrum via: 

Section 2: Legal Requirements of the Jurisdiction

Restrictions on Discount Rate:  (Explain This)

Discount Damages For
 

Tax Treatment: (Explain This)

Adjust Results for Income Taxes

Section 3: Injured Party Information

(in wrongful death cases the decedent is the 'injured party')

How did the injury occur:  Describe the Circumstances Leading to the Injury

Brief Description of the Injury:

Name: First: Last:  
Gender:   Ethnicity
Date of Birth:
Date of Death:  (if wrongful death)
Residence at Time of Injury: City: State:
Highest Degree Received:
Education planned for children: (if wrongful death)
Finance Children's Education?
Occupation at Date of Injury: Years in occupation
Employer at Date of Injury:

Section 4: Injured Party Earnings and Benefits

(in wrongful death cases the decedent is the 'injured party')

Partial Year Including the Injury Full Calendar Year Before Injury Full Calendar Year Two Years Before Injury Full Calendar Year Three Years before Injury
$/
Total
$		      
Total:
$		 Total:
$		 Total:
$

Employer Paid Benefits

Benefit Provided Details
401(k) Employer % Employee %
Medical Insurance
Dental Insurance
Life Insurance
Disability Insurance
Defined Benefit Plan (Pension)
Union Contract Benefits

Estimate the value of these benefits using:   %

If Wrongful Death of a Minor...

Grade level at time of death:   
Occupational Plans:    
Mother's Education Level    
Father's Education Level    

Household Services

Did the decdent provide an "average" quantity of services for the family and home (for example cooking, cleaning, etc.)?  If No (either more or less) explain and provide and estimate of the percentage difference from what would be considered average.

Other Information

Describe any additional information needed to understand earnings capability and earnings fluctuations after the injury.

Section 5: Injured Party's Actual Earnings After the injury

(Not applicable to Wrongful Death Cases)

Has the injured party obtained employment following the injury?

If the inured party HAS NOT obtained employment.

Is future employment expected? 

If Future Employment is Expected Without Retraining
Expected date of replacement employment   Month:    Year:
Identify future income based on statistics that fulcrum will provide
Expected future occupation
Expected location of future employment
If Future Employment Will First Require Retraining
Starting date of retraining program   Month:    Year:
Length of retraining program in months
Expected retraining cost $
Type of work expected after retraining
Typical current annual income of work expected after retraining $
If the Injured Party is a Minor
Grade level at time of injury:   
Pre-injury Occupational Plan:  
Revised Occupational Plan:
Mother's Education Level:  Occupation:
Father's Education Level:  Occupation:

If the Inured Party HAS Obtained Replacement Employment

Date first replacement employment began   Month:    Year:
Actual occupation afer injury:
Employer:
Second Full Calendar Year of Re-emplyoment Following Injury First Full Calendar Year of Re-Employment Following Injury First Partial Calendar Year of Re-emplyoment Following Injury
     
Total:
$		 Total:
$		 Total:
$
Benefit Before Injury Employer After Injury Employer Details of Differences
401(k)
Medical Insurance
Dental Insurance
Life Insurance
Disability Insurance
Defined Benefit Plan (Pension)
Union Contract Benefits

Estimate the value of these benefits using:   %

Describe any additional information needed to understand earnings capability and earnings fluctuations after the injury.

Section 6: Current/Future Medical Expenses

(Not Applicable in Wrongful Death Cases)

Medical expenses incurred prior to the date of the loss claim:  $ 
Expected future medical expenses $ / for
If the injured party is no longer able to provide the same level of household services (for example cooking, cleaning, etc.) indicate the level of reduction.  It is not necessary to list particular services.   % reduced
If the injured party as a result is required to reside in a health care facility or to hire live-in or part-time homehealth care aid, provide the current annual cost $ /year
If medical evidence indicates the injured party will have a reduced life expectancy, provide an estimate of the reduction. Years

Section 7: Dependent Information

(Wrongful Death Cases only)

  Dependent 1 Dependent 2 Dependent 3 Dependent 4 Dependent 5
First Name
Last Name
Relationship
Dependent's Gender
Dependent's Ethnicity
Dependent's Date of Birth
Dependent's highest degree recieved 
Was dependant residing with decedent at date of death?
Dependent's annual earning rate at decedent's death 
 $  $  $  $  $
Dependent's occupation at decedent's death