Workers Compensation

Daytime Phone

Street Address

City

State

Zip

Email Address

Date of Injury (MM/DD/YYYY)

Address, City, State where the injury occured

Date of Birth (MM/DD/YYYY)

Social Security Number (XXX-XX-XXXX)

Employer Name (At time of injury)

Employer Address, City, State, Zip

Date of Hire (MM/DD/YY)

Last Day of Work (MM/DD/YYYY)

Job Title

Wages ($$$ per time frame)

How many hours per week worked?

Body Parts Affected

Date Reported To Employer (MM/DD/YYYY)

Reported To Whom

Did you receive a claim form?

When did you return it to the employer?

Did your employer send you to a doctor ?

When (MM/DD/YYYY)

Name of Doctor you were sent to

Address of the Doctor you were sent to

Worker's Compensation Insurance Company

Address

Insurance Company Telephone Number

Claim Number

Adjuster

Are you receiving Temporary Disability Benefits?

From the Insurance Company or State Disability?

Who is your treating physician?

List any doctors (full name and addresses) that have treated you in the last 5 years (if possible)

Were you fired or discriminated against?

Was anyone else responsible for your injury?

Were you injured using faulty equipment?

Give a description of how the injury occured

Are you now, or have you been, represented by an attorney for this injury?

If so, please give the name, address and phone number of the attorney

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