Do you have a prior attorney, if so,
Please provide name and phone number of Attorney?: | |
| Your Name: | |
| E-mail address: | |
| Phone Number: | |
| Address: | |
| Type of Injury (WC or PI ,etc..): | |
| What was that Date & Time of Injury: | |
| Date Incident Reported: | |
| How did Injury Occur: | |
| What Body Parts were hurt: | |
| Name of Employer: | |
| Date Hired: | |
| Hourly Rate: | |
| Hours Worked per Week: | |
| What is your Occupation: | |
| Are you Still Suffering from the Injury: | |
| Are you Currently working for the Employer: | |
| If not, Did you Quit or were you fired?: | |
| If fired, who fired you and when? | |
| Did you miss any work since your injury, if so what days?: | |
| Are you currently receiving Benefits. If so What kind?: | |
Have you received medical treatment for your injury?
If so, Date of First Treatment and by whom?: | |
| Were you sent to employer's or your personal Doctor?: | |
| Are you still seeing receiving treatment? If not, when was the Last Appointment: | |
| Did you fill out a Claim Form?: | |
Who is the Employer's WC Insurance Carrier
and Claim Number?: | |
Have you ever been Involved in a Personal Injury Case? If so, What Year?
and What Body Parts?: | |
Have you ever been Involved in a Workers' Compensation Case? If so, What Year?
and What Body Parts?: | |
| Names of any Witnesses?: | |
| * |