Damages Questionnaire - PDF Templates

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Monday, March 10, 2025

Damages Questionnaire

Client Name:

Jennifer Kuch

Part I

Reimbursement

Medical Expenses

Did you have any out of pocket expenses or owe money related to your vaccine injury?

Yes (If you selected 'Yes', please complete the Spreadsheet file attached below)

This link will allow you to download your Out of Pocket spreadsheet: Downloadable Client OOP Spreadsheet

Did Medicaid pay for any treatment related to your vaccine injury?

If 'Yes', please provide proof of payment for ALL expenses (receipts, canceled checks, account statements) or dated invoices detailing any amounts still owed.

PDF

Out of Pocket Receipts.pdf

PDF

Payback of Benefits Receipt 2.pdf

PDF

Payback of Benefits Receipt 1.pdf

PDF

Payback of Benefits Receipt 3.pdf

XLSX

My Vaccine Lawyer_ Client OOP Spreadsheet .xlsx

Lost Earnings

Did you miss time from work due to your vaccine injury?

Yes

Did the missed tim

e result in lost e

arnings?

Yes

Approximately how much time did you miss from work?

9 months from Covenant Healthcare, 3 semesters from Delta College

How are you paid?

Hourly

What date did you return to work?

Tuesday, January 2, 2024

If you have not returned to work, when do you expect to return?

I was off two separate times from the hospital: 10/29/2022-12/14/2022 and then 5/19/2023 to 1/2/2024 total 9 months. I missed variable days at the College totalling 3 semesters

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Employer Name:

Covenant Healthcare and Delta College

Employer Name:

Covenant Healthcare and Delta College

Position/Job Title:

Registered nurse and adjunct nursing faculty instructor

Do we have permission to contact your employer?

Yes

HR Contact Name

Covenant Healthcare: Emily; Delta College anyone in HR

HR Contact Phone Number

Covenant Healthcare Fax 989-583-4882 attn: Emily; Delta College 989-686-9107 prompt 5

To receive reimbursement for lost earnings, please provide the following information.

This link will allow you to download your tax returns: www.irs.gov/individuals/get-transcript

W2 Forms and tax r

eturns for each of

the five (5) year

s prior to your va

ccination thru the

present year:

Proof of wages at the time of your vaccination (paystub, etc.):

PDF

2022 Covenant Paystub.pdf

PDF

2022 delta paystub.pdf

Any correspondence from your employer regarding the missed time (timecards, emails, requests for accommodations, etc.):

PDF

E-mails and Work Accommodations.pdf

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Other Benefits

Social Security

Please create an account using the link below and forward a copy of your income statement: https://www.ssa.gov/myaccount/

Did you apply for disability benefits?

Yes

Did you receive disability benefits?

Yes

If so, please identify the amount of $ received

This was not social security disability benefits, it was a short term disability claim and one payment of long term disability through Met Life

Workers' Compensation

Did you file a Workers’ Compensation claim?

Did you receive Workers’ Compensation benefits?

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Part II

Impact Statement

At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the Jotform system during and after the signing session. You may request delivery of such paper copies from us by emailing us at: info@myvaccinelawyer.com. In the body of such a request you must state your email address, full name, address, and telephone number.

In addition to any relevant reimbursement detailed above, you are entitled to compensation for your pain and suffering. The best way to demonstrate this is a specific and detailed statement. Please attach your statement, and be sure to mention the following aspects: Current pain level (1-10), Impact on sleep, if any, Anticipated additional treatment, Affected activities or hobbies; and Change in family, home or work life etc.

DOCX

Pain and Suffering Statement.docx