Workers Comp Form - created by phpFormGenerator

Workers' Compensation Form

Date
Last Name
First Name
Birthdate (age)
Address
City
State
Zip Code
Phone (home)
Phone (work)
Phone (message)
Date of injury
Claim #
Social Security #
Spouse name
Children names and ages
Who referred you to our office?
How did your injury happen?
Is your claim open? (Time loss rate)
Is your claim closed? (date)
Rejected? (date)
Other status?
Have you missed any time loss compensation? (dates claimed)
Describe your disability:
Who are your doctors?
Hospitalizations/Surgeries(dates):
Has the state or employer sent you to any doctors? (when)
Do you have medical insurance? (Group #)
Medical insurance I.D. #
Who has paid your medical bills?
Do you owe current or back child support payments? Describe:
Employer at time of injury:
Employed since?
Job at time of injury:
Date last worked:
Wages at time of injury:
What other kinds of work have you done?
Education:
Union Member? (local)
Prior industrial injuries? (claim numbers)
Disability awards? (dates/percentages)
Other significant medical problems?
Have you applied for or are you receiving Social Security? (when and results)
Since your injury, have you received Unemployment? (dates)
Since your injury, have you received Public Assistance? (dates)
Have you been represented in this claim by other attorneys?
Other information which would assist us in evaluating your claim:

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