Testing Survey form

AXIDENTLAWYERS VALUE ASSESSMENT TOOL

ARE YOU MALE OR FEMALE?

MALE

FEMALE

None

AGE:

SEX & AGE WILL HAVE VARIOUS MULTIPLYERS FOR CERTAIN THINGS. LIKE FOR HIP FRACTURES AND OTHER BONE FRACTURES, HIGH AGE INCREASES RISK SO HIGHER MULTIPLYER. FOR COSMETIC INJURIES, FEMALE AND LOW AGE HIGHER MULTIPLYER. FOR ANY FUNCTIONAL DEFICIT, LOWER THE AGE, THE HIGHER THE MULTIPLYER AS THE LONGER THE PERSON HAS TO SUFFER THE LOSS.

None

WHAT STATE DID THE ACCIDENT OCCUR IN?

ARE YOU ENQUIRING ON YOUR OWN BEHALF OR SOMEONE ELSE’S BEHALF?

MY OWN

SOME ONE ELSE

None

IF SOMEONE ELSE, IS THAT PERSON RELATED TO YOU?

YES

None

IF SOMEONE ELSE, DID THAT PERSON DIE AS A RESULT OF THE ACCIDENT?

YES

None

IF YOUR OWN, WERE YOU INJURED IN THE ACCIDENT?

YES

None

WERE THERE ANY WITNESSES?

YES

None

WERE PARAMEDICS CALLED?

YES

None

WAS THE POLICE CALLED?

YES

None

WAS A POLICE REPORT MADE?

YES

None

WERE YOU TRANSPORTERD TO A HOSPITAL?

YES

None

DID YOU GO TO AN URGENT CARE THE SAME DAY?

YES

None

DID YOU GO TO SEE A PHYSICIAN THE SAME DAY?

YES

None

DID YOU SEE A PHYSICIAN SHORTLY AFTER?

YES

None

ARE THERE INSURANCE COVERAGES IN FORECE TO COVER THE DAMAGES?

YES

None

DOES THE PARTY AT FAULT HAVE INSURANCE TO COVER YOUR DAMAGES?

YES

None

DO YOU HAVE INSURANCE TO COVER YOUR DAMAGES?

YES

None

WERE YOU SO SEVERELY INJURED THAT YOU COULD NOT WALK AFTER THE ACCIDENT?

YES

None

DID YOU SUFFER LOSS OF CONSCIOUSNESS AFTER THE ACCIDENT?

YES

None

DID YOU HAVE ANY OF THE FOLLOWING IMMEDIATELY AFTER THE ACCIDENT?

PANIC ATTACK $200

SEVERE ANXIETY $200

DIFFICULTY SPEAKING $200

NAUZEA $200

VOMITING $200

HEADACHE $200

DIZZINESS $200

BLURRED VISION$200

VISUAL PROBLEMS $200

NECK PAIN $3500

BACK ACHE $3500

CHESTWALL PAIN $500

CHESTPAIN $500

SHORTNESS OF BREATH $500

PARALYSIS $25000

BIFFICULTY WALKING $2000

DIFFICULTY USING HANDS $20,000

ABDOMINAL PAIN $10,000

NOSEBLEED $25000

BLOOD IN URINE $25000

BLOOD FROM RECTUM OR IN FECES $75000

ANY OTHER BLEEDING $5000

OTHER SYMPTOMS (Please add here)

None

Comment

HOW DID THE ACCIDENT HAPPEN?

CAR ACCIDENT $5,000

TRUCK ACCIDENT $10,000

BICYCLE ACCIDENT $15,000

BUS ACCIDENT $15,000

CONSTRUCTION ACCIDENTAL INJURY $15,000

DOG BITE $10,000

E-SCOOTER RENTAL $10,000

UBER/LYFT PASSENGER $50,000

UBER/LYFT DRIVER $50,000

MOTORCYCLE $150,000

PEDESTRIAN ACCIDENT $150,000

SLIP & FALL $80,000

TRAIN & RAIL ACCIDENT $80,000

PREMISES ACCIDENT $80,000

BIG RIG ACCIDENT $250,000

ATV ACCIDENT $150,000

AVIATION ACCIDENT $500,000

BOATING ACCIDENT $500,000

ELEVATOR ACCIDENT $300,000

ESCALATOR ACCIDENT $250,000

ELECTRIC SCOOTER ACCIDENT $200,000

MOTORIZED SCOOTER ACCIDEDENT $150,000

TRAIN ACCIDENT $100,000

WHIPLASH INJURY ACCIDENT $30,000

OTHER ----SPECIFY: Type here please>….

None

Comment

AS A RESULT OF THE ACCIDENT, HOW MANY OF THE FOLLOWING DID YOU SUFFER?

SKIN AND MUSCLE INJURY to HEAD $30,000

HEAD TRAUMATIC BRAIN INJURIES WITH BRAIN FUNCTION ISSUES $500,000

MEMORY LOSS $500,000

MENTAL FUNCTION CHANGES $500,000

NECK INJURY $100,000

BACK INJURY $100,000

BODY INJURY $50,000

AMPUTATION $1000,000

BROKEN BONES/FRACTURES $100,000

KNEE MENISCUS INJURIES $75000

HIP INJURY $100,000

ROTATOR CUFF INJURY $100,000

SPINAL COLUMN INJURY WITH NEUROLOGICAL PROBLEMS $250,000

EYE INJURY WITH VISUAL PROBLEMS $250,000

FACE INJURIES AND FACIAL DISFIGUREMENT $750,000 Men $1000,000 Women

SKIN AND TISSUE TEARS $100,000

BODY DISFIGUREMENTS $100,000

NOSE INJURIY $100,000

NOSE BREATHING PROBLEMS $100,000

SPLEEN INJURY $500,000

LIVER INJURY $500,000

BOWEL INJURY $500,000

BLADDER INJURY $500,000

LUNGS INJURY $750,000

KIDNEY INJURY $750,000

RIB FRACTURE $300,000

OTHER ORGAN INJURY $300,000

ORTHOPEDIC INJURIES $200,000

SPINAL CORD INJURIES $300,000

TRAUMATIC BRAIN INJURY (TBI) $750,000

BURN INJURY $500,000

DISFIGURMENT OF ANY KIND $500,000

LOSS OF A PART OF YOUR BODY (DISMEMBERMENT) $750,000

EYE INJURY OF ANY KIND $500,000

HAND INJURY $250,000

FOOT INJURY $300,000

HIP INJURY $400,000

KNEE INJURY OF ANY KIND $300,000

HIP FRACTURE $350,000

KNEE FRACTURE $300,000

ANKLE FRACTURE $100,000

ARM FRACTURE $100,000

NECK FRACTURE $250,000

SPINAL COLUMN FRACTURE $300,000

BONE FRACTURES CUTTING THROUGH THE SKIN $300,000

BONE FRACTURES WITH BONE PIECES MOVED APART FROM EACH OTHER BUT NOT THROUGH SKIN $75,000

BONE FRCTURES WITH FINE LINE FRACTURES $75,000

MULTIPLE BONE FRACTURES $150,000

EYE INJURIES WITH VISUAL CHANGES $500,000

INJURY LEADING TO INABILITY TO WALK NEEDING WHEELCHAIR PERMANENTLY $2,000,000

INJURY LEADING TO INABILITY TO WALK FOR A FEW WEEKS $100,000

INJURY LEADING TO INABILITY TO WORK FOR A FEW WEEKS $100,000

INJURY LEADING TO INABILITY TO USE ONE ARM FOR A FEW WEEKS $100,000

INJURY LEADING TO INABILITY TO USE BOTH ARMS FOR A FEW WEEKS $500,000

INJURY LEADING TO INABILITY TO USE BOTH ARMS PERMANENTLY $20,000,000

INJURY LEADING TO INABILITY TO CARE FOR YOURSELF NEEDING ASSISTANCE$10,000,000.

SPINAL CORD INJURY WITH PERMANENT NEUROLOGICAL DEFICIT TO ARMS AND LEGS $50,000,000

None

Comment

ARE ENQUIRING ON BEHALF OF SOMEONE WHO PASSED-AWAY IN THE ACCIDENT:

Wrongful Death

None

ARE YOU THE SPOUSE OF THE DECEASED?

YES

None

IF YOUR INJURY WAS NOT AS A RESULT OF AN ACCIDENT INVOLVING A MOTORCYCLE, A CAR, OR A FAMILY TYPE VEHICLE SUCH AS A SUV OR A SMALL TRUCK, THEN YOU ARE DONE WITH THIS ASSESSMENT AND YOU CAN NOW CONTACT OUR SERVICE CENTER FOR YOUR EVALUATION RESULT AT 213…… YOU WILL RECEIVE A $ FIGURE FROM THEM AS AN ESTIMATE FOR THE VALUE OF YOUR CLAIM FOR YOUR DAMAGES ONCE THEY CONFIRM THE RESPONSES TO A FEW OF THE QUESTIONS ABOVE, IF NEEDED!

None

IF YOUR INJURY WAS CAUSED AS A RESULT OF A MOTORCYCLE, CAR, FAMILY TRUCK, SUV ACCIDENT, PLEASE CONTINUE TO ANSWER THE FOLLOWING QUESTIONS:

WHAT KIND OF VEHICLE?

MOTORCYCLE

CAR

SUV

SMALL-MEDIUM PASSENGER TRUCK

4X4/LARGE PASSENGER TRUCK

None

WERE YOU THE DRIVER?

YES

NO $5,000

None

HOW WAS YOUR VEHICLE INVOLVED IN THE ACCIDENT?

OUR VEHICLE HIT THE OTHER VEHICLE (CASE MAY NOT BE GOOD)

THE OTHER VEHICLE HIT OUR VEHICLE

None

HOW MUCH DO YOU ESTIMATE THE DAMAGE TO YOUR VEHICLE WAS?

LESS THAN $1500.00 (CASE MAY NOT BE GOOD)

1500 TO $10,000.00

$10,000.00 TO $20,000.00

$20,000.00 TO $30,000.00

MORE THAN $30,000.00

THE VEHICLE WAS TOTALLED AND NOT DRIVABLE.

None

HOW DID THE ACCIDENT HAPPEN?

THE OTHER VEHICLE BROKE THE LAW AND CAUSED THE ACCIDENT

THE OTHER VEHICLE PASSED THE RED LIGHT AND CAUSED THE ACCIDENT

THE OTHER VEHICLE PULLED IN FRONT OF US INTENTIONALLY

THE OTHER VEHICLE SUDDENLY HIT THE BREAKS TO CAUSE THE ACCIDENT

THE OTHER VEHICLE SIDE SWIPED OUR CAR

THE OTHER VEHICLE HIT OUR CAR FROM THE BACK

THE OTHER VEHICLE HIT OUR CAR FROM THE BACK AND DROVE US INTO THE CAR IN FRONT

OTHER (Describe briefly please:)

None

Comment

THE ACCIDENT HAPPENNED IN THE FREEWAY WHILE OUR CAR WAS AT:

FULL STOP

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING AT 65 MILES PER HOUR OR MORE

None

THE ACCIDENT HAPPENNED IN THE FREEWAY WHILE THE OTHER CAR WAS MOVING:

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING ABOVE 65 MOLE PER HOUR

None

Comment

THE ACCIDENT HAPPENNED IN THE STREET WHILE OUR CAR WAS AT:

FULL STOP

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING AT 65 MILES PER HOUR OR MORE

None

Comment

THE ACCIDENT HAPPENNED IN THE STREET WHILE THE OTHER CAR WAS MOVING:

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING ABOVE 65 MOLE PER HOUR

None

Comment

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