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RAFFA CONSULTING ECONOMISTS, INC.

WRONGFUL DEATH WORKSHEET

 

DECEDENT'S NAME:  

                ATTORNEY:        PHONE NO:

 FAMILY CONTACT:         PHONE NO: 

I. DECEDENT'S BACKGROUND INFORMATION

Date of Birth

Sex

Race

Country/State of Residence

Educational Attainment

Anticipated Retirement Age

II. FAMILY MEMBERS/CLAIMANTS

Name

Relationship to the Decedent

Date of Birth

Reside with Decedent?

Amount of Child Support, if Applicable

III. EMPLOYMENT/EARNINGS HISTORY1

Employer

Position

Year

Gross Earnings

Gross Earnings

Gross Earnings

Gross Earnings

Combined Gross Earnings
1997

1998

1999

2000

2001

1-Please confirm with copies of W-2 forms or an IRS Records Request.

IV. COMPANY-PAID FRINGE BENEFITS

Please check "Yes" if the decedent's most recent employer made contributions towards any of the following fringe benefits:

  A.    Retirement and Savings Plan Payments

  1. Defined Benefit Pension Plan Contributions . . . . .   
  2. 401K and Similar                           . . . . .         
  3. Profit Sharing                               . . . .   
  4. Stock Bonus, Employee Stock Ownership Plans . . . . .  
  5. Other Retirement Plan                     . . . . . .                   

  B.    Medical and Medically-Related Benefit Payments

  1. Health Insurance Coverage                  . . . . .   
  2. Dental Insurance Coverage                  . . . . .   
  3. Vision Care Coverage                       . . . . .   
  4. Prescription Drug Coverage                 . . . . .        

  C.    Miscellaneous Benefit Programs

  1. Employee Education Expenditures (tuition, etc.)   . .     
  2. Other (Please Specify)                            . .  

V. DECEDENT'S PERSONAL CONSUMPTION EXPENDITURES

  A.  If possible, please provide your best estimate of the weekly/monthly/annual (please circle one) spending by the decedent  for:

  1. Food                      . . . . .   
  2. Clothing                  . . . . .   
  3. Transportation            . . . . .   
  4. Medical/Health Care       . . . . .    
  5. Recreation/Entertainment  . . . . .    
  6. Misc./Other               . . . . .   

OR

  B. If you have no financial records or are otherwise unable to estimate the decedent's personal spending, would you consider his/her spending habits, given the amount of family income and the number of family members, to be (check one):

  1. Average                . . . . .   
  2. Above Average          . . . . .   
  3. Below Average          . . . . .   

VI. LOSS OF HOUSEHOLD/CHILDCARE SERVICES

     As a result of the death of an individual, the surviving family members sustain a loss of their services in and around the home.  Survey data suggest that the average person spends the following time performing services in and around the home:

 * Males on average spend 15 hours per week

   * Females on average spend 40 hours per week

 

   - Given your knowledge, would you consider the decedent be average?  Yes   No*

*If "No", please complete the following:

  1. Housekeeping/Cooking (vacuuming, dusting, laundry, cooking)  . . . . .  Hrs/Wk
  2. Shopping/Goods Buying (groceries, clothing, household supplies)  . . .  Hrs/Wk
  3. Repair and Maintenance (home, auto, boat, yard work)          . . . .   Hrs/Wk
  4. Miscellaneous (bill paying, tax preparation, etc.)          . . . . .  Hrs/Wk
  5. Child/Dependent Care (supervising, chauffeuring, etc.)      . . . . .   Hrs/Wk

VII. INSURANCE BENEFITS

     As a surviving family member, have you received any financial payments from private or employer-funded life insurance; or any other death benefit program (such as from pension funds or union insurance programs) - check one:

 No   Yes*

 

       *If "Yes", please list the source and amount of insurance benefits received, as well as the name of an insurance company or benefit provider representative who can be contacted concerning the specific terms under which this life insurance or related death benefit was created:

Source of Insurance Benefit/Name of Insurer

Amount of Insurance Benefit You Received

Contact Person at Insurance Company

Telephone Number for Contact Person

 

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