Workers’ Compensation Case Questionnaire

Name *

First

Last

Spouse Name

First

Last

Date of Birth *

Street Address *

City *

State *

Zip *

Phone Number *

Email *

Do You Require an Interpreter? *

Yes
No

Employer Information *

Employer's Phone Number *

Date of Employment *

Job Title *

Wage/Salary *

Number of hours scheduled to work per week?

Do you have a second job? *

Yes
No

Have you been terminated/laid off from this job? *

Yes
No

If you are currently working, what day did you return to work?

If you are not working, what was your last day of work?

What date did you report your accident/injury to employer?

Type of accident/injury/illness: *

Have you ever consulted another attorney about this accident/injury/illness?

Yes
No

Date of accident/injury (or beginning date of illness)

Ending date of illness (if applicable)

Address where injury occurred:

At work
Elsewhere

If elsewhere, please describe:

Time of injury (AM/PM):

Parts of body injured:

How did the injury/illness occur? *

Who is responsible for the injury/illness? (Please check all that apply)

Please explain the responsibility of any checked above.

Please list your current doctor(s) name and phone number related to this incident.

Please list other doctors/hospitals you have seen for this injury/illness:

Were you hospitalized overnight? *

Yes
No

Name of Workers' Compensation Insurance Company: *

Workers' Compensation Insurance Company Phone: *

Name of Claims Adjuster:

First

Last

Claim Adjuster Phone Number:

Claim Number:

Has your claim been denied?

Yes
No

Do you have private medical insurance? *

Yes
No

Who paid for your treatment?

Please list all unpaid medical bills and include amounts due:

Please list the start and end dates you did not work due to injury or illness: *

Please list the start and end dates you received Workers' Compensation Benefits:

Have you applied for Social Security Disability? *

Yes
No

Please list any type of benefits, amounts and dates received from other sources:

Include State Disability, Unemployment, Social Security, Long Term Disability, Retirement/Pension, or any other source of benefits.

Have you ever injured this body part before? *

Yes
No

If previous injury exists, did it occur at work or elsewhere? *

Work
Elsewhere

Have you ever had any other on-the-job injuries/illnesses? *

Yes
No

Any prior workers' compensation claims? *

Yes
No

Have you had any off-the-job injuries/illnesses? *

Yes
No

Please list any doctors/hospitals you have seen due to the above listed injuries/illnesses or workers' compensation claims:

Have you ever filed a claim or lawsuit for a work injury or personal injury? *

Yes
No

List other medical conditions that limit your ability to work and/or require ongoing medical care:

Heart disease, arthritis, etc.

Please list any doctors/hospitals you have seen for the above medical conditions:

Agreement *

I have read, understand and agree to the Terms and Conditions

By sending us your completed questionnaire, you will be asking us to look at your case and to consider representing you. Sending us a completed questionnaire does NOT mean that we will take your case. All communications from you to us will be kept strictly confidential regardless of whether we become your attorneys.

Please also be aware that sending us a completed questionnaire does not mean that we will take any action to preserve your rights or to file a timely claim or lawsuit unless we accept your case and agree to represent you.

All legal claims have time limits for filing. It is always wise to seek the opinion of a qualified, competent attorney as soon as possible after an injury occurs so that evidence may be gathered and preserved, and important deadlines can be met in order to hold all responsible parties accountable.

By clicking “I Accept,” you confirm that you have read the terms and conditions stated above, and that you agree to be bound by them.

*Please complete the following questions to the best of your ability. We understand that there may be a need to change or add information at a later time.

HOLLADAY OFFICE

phone | (801) 424-9675

fax | (801) 683-7575

OFFICE HOURS

Monday – Friday:
8:00 am – 6:00 pm

PRACTICE AREAS

Workers’ Compensation Case Questionnaire

*Please complete the following questions to the best of your ability. We understand that there may be a need to change or add information at a later time.

HOLLADAY OFFICE

phone | (801) 424-9675

fax | (801) 683-7575

OFFICE HOURS

Monday – Friday: 8:00 am – 6:00 pm

PRACTICE AREAS

Monday – Friday:
8:00 am – 6:00 pm