EMERGENCY CONTACT - If we’re unable to reach you at your home address and phone number listed above:
For each work injury, list the date, part of body hurt, and a brief description of how you were hurt:
If yes, same job/duties/pay?
Please find a recent piece of correspondence (if any) & complete the following about the insurance carrier:
FOR LONGSHORE: Has the claim been controverted? If yes, we need a copy of the notice.
Any WCAB Hearings or Awards?
Have you received any money from Workers’ Compensation?
Have you received disability payments other than workers’ compensation?
CLIENT TO COMPLETE THE FOLLOWING SECTIONS AS COMPLETELY AS POSSIBLE
WORK INJURY TREATMENT Please list below any doctors, hospitals, or clinics you have been to for treatment of your work injury (List Current Treating Doctors First):
OTHER MEDICAL CONDITIONS & INJURIES Other than your medical problems related to your current work injury, please list all other major medical problems you have had in the past. Please also provide us the doctor’s name, address, phone number, and approximately when you were treated.