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 job separation: If possible, this form should be completed by the individual whose employment was terminated. Ideally, this form would be completed by both the terminated individual and the attorney or their support staff who has retained me to make determination on the individual's loss. Please answer all appropriate questions. If you do not understand a question, please contact me using the above information. 

I. General information regarding the terminated individual

  name:  
date of birth:   ,
  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. Events surrounding termination
 

  

 date of termination:   ,
  describe the events leading up the the individual's termination:   
  provide a timeline of important dates relevant to the termination:   
 

III. Pre-termination employment
 

  

 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:  
job-related expenses:   

 

III. Post-termination employment (if inapplicable, leave blank)
 

  

 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:  
  job-related expenses:   

 
V. Contact information for counsel
 

  

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