Personal Injury Settlement Consulting Questionnaire

Does my client have adequate medical insurance; i.e., if my client has Medicare, does he have a Medicare supplement?

Yes
No

Is my client entitled to any public benefits he is not currently receiving such as SSI, Medicaid, Medicaid Waiver Program, New Jersey Family Care, Section 8 Housing, Group Home, Food Stamps, or Psychiatric Institutionalization?

Yes
No

Has my client obtained advice concerning Federal and State estate taxes and income taxes?

Yes
No

Does my client have a Will, Living Trust, Living Will, and Power of Attorney? If my client is a minor or incapacitated person, do my client’s parents have a Third Party Special Needs Trust?

Yes
No

Have I obtained a competent investment advisor or professional trustee for my client?

Yes
No

Does my client need a Special Needs trust?

Yes
No

Note: See separate questionnaire, does my client need a special needs trust?

Would my client benefit from a Settlement Preservation Trust?

Yes
No

Note: These trusts are particularly useful if the client is a minor or incapacitated person who is not receiving or likely to receive means-tested public benefits such as SSI and Medicaid or if my client needs assistance with money management.

Is a Medicare Set-Aside Arrangement required?

Yes
No

Note: See separate questionnaire, is a Medicare Set-Aside Arrangement (MSA) required?

Would my client benefit from a structured settlement?

Yes
No

Have all liens been satisfied or reduced; including:

Medicaid

Yes
No

Medicare Advantage Plan

Yes
No

Medicare Part D

Yes
No

ARISA

Yes
No

State Worker’s Compensation

Yes
No

Federal Worker’s Compensation

Yes
No

Hospital Lien

Yes
No

Veteran’s Administration Claims

Yes
No

Federal Employee Health Benefits Act

Yes
No

Welfare Liens

Yes
No

Mental Health Liens

Yes
No

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