JOHN HILL

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 P.O. Box 21
Abilene, Texas 79604

750 N. Judge Ely Blvd.
Abilene, Texas 79601

university office: (325) 670-5871
personal office: (325) 672-4807
cell: (325) 721-4428
facsimile: (325) 677-3500

Questionnaire for the determination of loss associated with the deceased: If possible, this form should be completed by the individual's family or someone familiar with deceased person's situation at the time of death. Ideally, this form would be completed with the assistance of the case attorneys or their support staff. Please answer all appropriate questions. If you do not understand a question, please contact me using the above information. 
I. General information regarding the deceased individual
 
  name:  
  date of birth:   ,
  date of death:  ,
  marital status:  
  gender:  
  race:   
  street address:  
  city, state and zip code:  
  contact phone for family:  
  contact email for family:  
  highest level of education:  
  years of education:   
  special licenses or skills:  
  case name:   
 
II. Family members living at home with deceased individual at time of death along with their date of birth (leave blank if not applicable)
 

  

 name of spouse:  
  spouse's date of birth:    ,
  name of first child:   
first child's date of birth:     ,
  name of second child:   
  second child's date of birth:     ,
  name of third child:   
third child's date of birth:     ,
  name of fourth child:   
  fourth child's date of birth:     ,
  Other information about family:     
 

III.  Employment at time of death
 

  

 name of employer:   
  start date of employment:    ,
  nature of work performed:    
  income:      paid 
hours worked per week:    
  overtime worked per week:    
promotions:     
  life insurance:     yes     no
  individual health insurance:    yes     no
  family health insurance:    yes     no
  long-term disability insurance:  yes     no
  short-term disability insurance:    yes     no
  employer 401k match:    yes     no 
  pension plan:    yes     no
bonus plan:    yes     no
  stock option:    yes     no
  paid vacation:     yes     no
  other benefits:  
  anticipated age at retirement:  
 
IV. Household services performed by deceased, in hours per week
 

   

 meal preparation:  
  laundry:  
  auto repair:  
  child care:  
  yard work:  
  home repair:  
  cleaning:  
  manage home (ex. bill paying):  
  other (describe & include hours):
 
V. Contact information for counsel
 

  

 attorney:  
  alternate contact:  
  street address:  
  city, state, & zip code:  
  phone:  
  facsimile:  
  email: