Eaton Fire Damages Questionnaire

Instructions

This questionnaire may be completed by an individual plaintiff or multiple individuals within a household
All fields are optional - complete what you can
For minors, deceased, or incapacitated individuals, an Authorized Representative should complete this form
You can save your progress and return later

I Fire Victim Identification ▼

1. Plaintiff Information

Plaintiff 1

Plaintiff Type

Plaintiff Name (Full Legal Name)

Date of Birth

Employer ID Number (EIN) - For Business Plaintiffs Only

2. Authorized Business Representative (For Business Plaintiffs)

First Name

Last Name

Middle Initial

Suffix

Title

3. Loss Location(s)

A Loss Location is the place where you suffered harm (home, business, place of injury, or evacuation location). Do not provide P.O. Boxes.

Loss Location 1

Street Address

Apt/Suite/Lot Number

City

State

Zip Code

Country

APN (Assessor's Parcel Number) - if known

4. Attorney Representation

Are you represented by an attorney?

Yes No

Name of Law Firm

II Real Property Damage ▼

Are you submitting a claim for Real Property damage?

Yes No

B. Residential Real Property

Does your property claim include a dwelling that was damaged by the Fire?

Yes No

Type of dwelling

Year residence built

Year you purchased residence

Type of construction and materials

Composition of the roof

Major remodeling projects (year and description)

Size of dwelling (sq ft)

Additional square footage

Number of bedrooms

Number of bathrooms

At the time of the Fire, were you renting out the dwelling?

Yes No Partial

Description of any luxury amenities

Was the dwelling uninhabitable after the fire?

Yes No

Were you displaced from the property? If yes, provide the date.

Cost quoted or paid to repair/rebuild residence

C. Commercial Real Property

Does your claim include a commercial structure that was damaged or destroyed?

Yes No

Type of Structure

Size (sq ft)

Construction date

Cost quoted or paid to repair/rebuild commercial structure

D. Other Structures/Outbuildings

Does your claim include other structures (barn, detached garage, outbuilding, shed)?

Yes No

Describe the type of structure(s)

Roof composition

Size (sq ft)

Construction date

Features (check all that apply)

Electricity Permanent Foundation Plumbing

Cost quoted or paid to repair/rebuild

E. Amenities

Does your property claim include any of the following? (check all that apply)

Fencing Swimming Pool Retaining Walls Culverts Solar Panels Irrigation System Water Well or Tank

Describe any amenities that were damaged or destroyed

Cost quoted or paid to repair/rebuild amenities

F. Forestry/Landscaping

Does your claim include landscaping, shrubbery, vegetation, or forestry?

Yes No

Describe the type and quantity of landscaping damaged or destroyed

Type of damage to ornamental trees and landscaping

Total Loss Partial Loss Smoke Damage Only

Damaged or destroyed forestry acreage

Cost quoted or paid to restore landscaping/forestry

Did your property contain agriculture or livestock?

Yes No

If yes, describe agriculture/livestock and associated damages

III Personal Property Claims ▼

Does any part of your claim relate to damage to personal property you owned at the time of the Fire?

Personal property includes furniture, clothing, household items, automobiles, and other movable property.

Yes No

Description of damaged/destroyed personal property

Does your claim include any item or collection valued at more than $10,000?

Yes No

If yes, describe the item(s) or collection(s) including any professional appraisals

Have you removed any personal property from your property after the fire?

Do you have a pet that was injured as a result of the Fire?

Yes No

If yes, describe pet type, treatment received, and costs

Estimated value of your destroyed or damaged personal property

IV Other Property Damage ▼

Did you suffer any property loss other than real and/or personal property damage indicated above?

Yes No

Brief description of the damaged property

Cost quoted or paid to repair/rebuild this property

V Business Income Loss ▼

Are you submitting a claim for lost profits on behalf of a business affected by the Fire?

If you are a sole proprietor filing taxes on Form 1040 with Schedule C, E, or F, you are considered a business plaintiff.

Yes No

VI Personal Income Loss (Lost Wages) ▼

Does your claim for lost wages relate to:

Physical injury from the Fire Damage to your property Evacuation and/or displacement Damage to employer's property

Employer Information

Employer Name

Employer Address

Employer Phone

Employer EIN

Employment Information

Employment Start Date

Employment End Date (if applicable)

Length of Time Out of Work

Wage/Salary

Total Lost Wages

Do you claim you will continue to lose income in the future?

Yes No

If yes, estimate of future lost income and duration

Have you obtained other employment since the Fire?

Yes No

If yes, provide current employer, start date, and wage/salary

VII Emotional Distress ▼

B. Substantial Interference with Use or Enjoyment of Property

Did you experience emotional distress from the loss of use or enjoyment of your property?

Yes No

Your relationship to the property

Rent Own Other

Did you lose sentimental or irreplaceable personal property in the Fire?

Yes No

If yes, describe this personal property

VIII Personal Injury ▼

As a result of the Fire, did you suffer a personal injury?

Personal injury means a physical bodily injury or mental health condition resulting from the Fire.

Yes No

Did the injury require hospitalization?

Yes No

Injury Type

Injury Date

Medical Provider/Facility

Treatment Start Date

Treatment End Date

Description of Treatment

Dollar value of your claim for medical billings to date

Describe any ongoing treatment

If you were diagnosed with or treated for the same condition in the five years prior to the fire, please describe

Amount claimed for medical/mental health treatment reimbursement

IX Additional Living Expenses ▼

Did you relocate from your residence as a result of the Fire?

Yes No

Location(s) to which you relocated and approximate dates

Additional costs associated with relocating

Other out-of-pocket expenses from displacement

X Wrongful Death ▼

Are you asserting a claim for wrongful death?

Yes No

Name of the decedent

Date of birth

Where did the decedent live at the time of the fire?

Location of decedent's death

What do you contend caused decedent's death?

Relationship between decedent and each plaintiff asserting a claim

Who lived in the same home with decedent at the time of death? For how long?

Decedent's job at the time of death

Health conditions decedent suffered from that were not a cause of death

Medications decedent was taking at the time of death

XI Other Damages ▼

Are you claiming damages not covered in any other section?

Yes No

Briefly explain the nature of the claim(s) and requested compensation

XII Medical Insurance Information ▼

Do you or any family member have medical insurance that covers injuries listed in Section VIII?

Yes No

Federal Healthcare Programs (Medicare, Medicaid, TRICARE, etc.)

Private Healthcare Insurance

Have you lived in any state other than California since the Fire?

Yes No

XIII Other Insurance Information ▼

Did you submit an insurance claim for any property damage or business losses?

Yes No

Name of Insurance Carrier

Insurance Policy Number

Insurance Claim Number

XIV Other Assistance ▼

Have you received assistance from SBA, FEMA, LA County, State of California, or any non-profit over $1,000?

Yes No

Describe assistance received

Did you participate in any government-sponsored debris removal program?

Yes No

If yes, identify the program

XV Bankruptcy ▼

Has any plaintiff been a debtor in a bankruptcy proceeding that commenced on/after the date of the Fire or was open on the date of the Fire?

Yes No

* Contact Information ▼

Please provide your contact information so we can follow up with you.

Email Address

Phone Number

Preferred Contact Method

Email Phone Either

Additional Notes or Comments

By submitting this form, you confirm that the information provided is accurate to the best of your knowledge.

Eaton Fire Litigation

Individual Plaintiff Damages Questionnaire

Instructions

1. Plaintiff Information

Plaintiff 1

2. Authorized Business Representative (For Business Plaintiffs)

3. Loss Location(s)

Loss Location 1

4. Attorney Representation

A. Property Identification

B. Residential Real Property

C. Commercial Real Property

D. Other Structures/Outbuildings

E. Amenities

F. Forestry/Landscaping

Business Information

Employer Information

Employment Information

A. Evacuation and Proximity to the Fire

B. Substantial Interference with Use or Enjoyment of Property