Why Hire An Attorney
Workers Comp Injury
Construction & Industrial Accidents
Death Caused By a Workplace Injury or Illness
Work Related Injuries
Injured From a Fall At Work?
If Your Employer Doesn’t Have Workers’ Compensation Insurance
Workers Comp Intake Form
HOW DID YOU HEAR ABOUT US?
DATE OF BIRTH
SOCIAL SECURITY NO.
EMERGENCY CONTACT & PHONE NUMBER/S
ARE YOU MARRIED
Does your employer go by other names?
How Many Employees Work At The Employer?
What Does The Company Do?
Your Job Title
What Are Your Job Duties?
How Many Hours Per Day Do You Work?
Your Rate Of Pay
How Often Are You Paid?
WHICH BODY PARTS WERE INJURED & DESCRIBE HOW YOUR INJURIES HAPPENED
Did Your Employer Send You To A Doctor, Hospital Or Medical Facility?
Did You Have Any Xrays, MRI Or CT scan?
Are You Still Seeing That Doctor? Or Are You Seeing Other Doctors?
Did You Go To A Doctor On Your Own?
Did The Doctor Take You Off Work?
Did The Doctor Give You Work Restrictions?
Are you receiving any bills from any medical facility for your workers’ comp injuries?
Drag and Drop (or)
PLEASE INDICATE WHICH OF YOUR BODY PARTS WERE INJURED
ENTER THE NUMBER/S AS SHOWN IN THE IMAGE BELOW
Employers Worker’s Comp Insurance Carrier
Is there any other information that you would like to bring to the attorney’s attention regarding this Date of Injury?
Are You Receiving Workers’ Comp TTD Payments?
When Did Your Payments Start?
How Much Are You Receiving?
PRIOR WORKERS COMPENSATION CLAIMS
Have You Been In a Previous Workers’ Comp Injury?:
Which Body Parts Were Injured?
Which Doctor/s Did You See For That Date Of Injury?