Damages Questionnaire for My Vaccine Lawyer

Client Name:*

First NameLast Name

Most recent date you were seen by a medical provider for your injury:*

Date

Please list the provider's name, address and contact information:*

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)No (If you selected 'No', please move to the next question)

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?

YesNo

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

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Estimated total $ paid for treatment or medical equipment related to your injury:*

Estimated total $ outstanding:*

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

YesNo (If you selected 'No', please move to Part III)

Did the missed time result in lost earnings?

YesNo (If you selected 'No', please move to Part III)

Approximately how much time did you miss from work?

How are you paid?

HourlySalaryOther

What date did you return to work?

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

Employer Name:

Position/Job Title:

Do we have permission to contact your employer?

YesNo

HR Contact Name

HR Contact Phone Number

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

W2 Forms and tax returns for each of the five (5) years prior to your vaccination thru the present year:

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

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

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Please enter your full Social Security Number (required to move forward with settlement):*

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?*

YesNo

Did you receive disability benefits?*

YesNo

If so, please identify the amount of $ received

Please provide any and all documentation related to your disability benefits

Did you file a Workers’ Compensation claim?*

YesNo

Did you receive Workers’ Compensation benefits?*

YesNo

If so, please identify the amount of $ received

Please provide any and all documentation related to your Workers’ Compensation claim

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.*

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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.

Damages Questionnaire

Part I

Part II

Medical Expenses

Lost Earnings

Other Benefits

Social Security

Workers' Compensation

Part III