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. Please enable JavaScript in your browser to complete this form.Name *FirstLastSpouse NameFirstLastDate of Birth *Street Address *City *State *Zip *Phone Number *Email *Do You Require an Interpreter? *YesNoEmployer 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? *YesNoHave you been terminated/laid off from this job? *YesNoIf 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?YesNoDate of accident/injury (or beginning date of illness)Ending date of illness (if applicable)Address where injury occurred:At workElsewhere 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)EmployerCo-EmployeeSomeone ElseUnsafe ConditionMachineChemical SubstancePlease 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? *YesNoName of Workers' Compensation Insurance Company: *Workers' Compensation Insurance Company Phone: *Name of Claims Adjuster:FirstLastClaim Adjuster Phone Number:Claim Number:Has your claim been denied?YesNoDo you have private medical insurance? *YesNoWho paid for your treatment?Workers' Compensation InsurancePrivate Medical insuranceMedicaid (State)Medicare (Federal)YourselfPlease 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? *YesNoPlease 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? *YesNoIf previous injury exists, did it occur at work or elsewhere? *WorkElsewhereHave you ever had any other on-the-job injuries/illnesses? *YesNoAny prior workers' compensation claims? *YesNoHave you had any off-the-job injuries/illnesses? *YesNoPlease 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? *YesNoList 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 ConditionsBy 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.EmailSubmit
