Information Form

The following is a guide to help the attorney in accumulating data for an Award to be valued. The categories of loss are those into which elements of loss are most often summarized. They are Pain and Suffering, Medical Expenses and Economic or Pecuniary Loss. Element titles may be any descriptive. Losses can be compensated by either periodic or lump sum payments (discrete), and discrete payments can be either one-time or recurring events.

Losses can either be past or future. Past Damages can be thought of in two parts, those expenses immediately incident to the event of loss and continuing expenses that are added to past damages through the passage of time. For purposes of developing a total Award, the attorney should take into consideration the timing of the event of loss, the amount of first payment in future dollars, the sequence of payment, and any annual inflation that occurs after the first year of payment (often referred to as COLA). For purposes of valuing an award for future damages, all payments for loss are considered periodic with initial payment occurring in the immediate future. (In fact, initial payments are first payable on the date of the verdict unless otherwise agreed by the parties or specified in the verdict.)

a.) Case Caption: ________________________________________________

b.) County of Filing: _______________________________________________

c.) Docket: _____________________________________________________

d.) Plaintiff: _____________________________________________________

e.) DOB: ___________ Sex: _________ Life Expectancy: _________________

f.) Decedent: _____________________ Date of Death: _______________

g.) DOB :___________ Sex: _________ Life Expect. at Death Time:__________

h.) 50B: _________50B Wrongful Death:___________

i.) Date of Event: ___________ Date from which losses began:___________

(There appears to be no special rules for dealing with wrongful death actions under the General Liability Award statutes (50B). Future damages are to be paid over the period/periods contained in the jury verdict.)

Litigation Expenses: _____________

Past Damages: _____________

a.) Damages Incident to Event of Loss-Amount: _____________

b.) Period of Payment: ____________ (Maximum 10 years)

c.) Amount: _______________

a.) Description: ____________________________________________

b.) Damages incident to Event of Loss-Amount: _____________

Periodic (Simple)

i.) Period for Payment _______Years, _____Months

ii.) Payment Sequence (Monthly etc.)_______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

vi.) Annual Inflation (Cola) after first Payment

Periodic (Complex)

i.) Period for Payment _______Years, _____Months

ii.) Payment Sequence (Monthly etc.)_______________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

Taxes Associated with Lost or Impaired Earnings (While there is no statutory provision for incorporating taxes in an Award under 50B, it is possible that it could be included in calculating lost or impaired earning amounts.)

Statutory Rates: __Simple __Pooled

Federal Rate______ applies to ______% of Earnings

State Rate _______ applies to ______% of Earnings

Local Rate _______ applies to ______% of Earnings

Year 1       Year 2       Year 3

Earnings      ________ ________ ________

Fed. Tax      ________ ________ ________

State Tax     ________ ________ ________

Local Tax     ________ ________ ________

3.) Loss of Services. (Services are pecuniary losses that are reasonably certain to be incurred and necessitated by plaintiff's injuries or the loss of decedent.)

a.) Description:____________________________________________

b.) Damages incident to Event of Loss-Amount:_____________

c.) Periodic

i.) Period for Payment _______Years, _____Months

ii.) Payment Sequence (Monthly etc.)_______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

vi.) Annual Inflation (Cola) after first Payment _________%

4.) Loss of Consortium (Generally, New York restricts payments to items of pecuniary loss, though there are references to Loss of Consortium in case law and in the statutes. To the extent that a claim can be made, it should be joined, where possible, with the underlying action. Under Sec. 4111, 50A Awards are to be returned by the jury in total without reference to period over which to be paid.)

a.) Description: ____________________________________________

b.) Damages incident to Event of Loss-Amount: _____________

c.) Periodic

i.) Period for Payment _______Years, _____Months

ii.) Payment Sequence (Monthly etc.)_______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

vi.) Annual Inflation (Cola) after first Payment _________%

a.) Description: ____________________________________________

b.) Damages incident to Event of Loss-Amount: _____________

c.) Periodic

i.) Period for Payment _______Years, _____Months

ii.) Payment Sequence (Monthly etc.)_______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

vi.) Annual Inflation (Cola) after first Payment _________%

d.) Discrete (Lump Sum Payments)

i.) Number of Events ____________

ii.) Payment Sequence (every 2, 3 or 4 years etc) _______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

vi.) Annual Inflation (Cola) after first Payment ________%

a.) Description:____________________________________________

b.) Damages incident to Event of Loss-Amount: _____________

c.) Periodic

i.) Period for Payment _______Years, _____Months

ii.) Payment Sequence (Monthly etc.)_______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

vi.) Annual Inflation (Cola) after first Payment

d.) Discrete (Lump Sum Payments)

i.) Number of Events ____________

ii.) Payment Sequence (every 2, 3 or 4 years etc) _______________

iii.) First Payment Date_____________

iv.) Current Cost_____________

v.) Annual Inflation rate to be Applied to reach 1^st. Payment______________

vi.) Annual Inflation (Cola) after first Payment

7.) Collateral Source Payments (Offsets). These are obligations to pay occasioned by the loss, e.g. Social Security Survivor Benefits. There must a reasonable certainty of payment (subject only to the continued payment of premium and such other financial obligations as occasioned by the agreement), and the source must not be entitled to a statutory lien. Collateral Source obligations may also apply to care, custodial care and rehabilitative care, though it is difficult to envision any where the only condition to delivery of care is continued premium payment.

i.) Description_________________________________________

ii.) Period for Payment _______Years, _____Months

iii.) Payment Sequence (Monthly etc.)_______________

iii.) First Payment Date_____________

iv.) Current Payment Amount_____________

v.) COLA Applicable _________%

vi.) Cost of Maintenance (last two years)___________

vii.) Ongoing Cost to Maintain______________

viii.) Inflation on Ongoing Cost______________

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Last modified: January 8, 2008