Free Consultation:
800-964-8047
Español
Home
About
Practice Areas
Workers Compensation
Workers Comp Attorneys
Workers Comp Benefits
Carpenters & Contractors
Workers Comp FAQs
Trabajadores Comp en Español
Social Security Disability
Social Security Attorneys
About Social Security Disability
Applying for Social Security Disability
Social Security FAQs Pt. 1
Social Security FAQs Pt. 2
Seguro Social en Español
Longshore Workers
Longshore Attorneys
Longshore FAQs
Defense Base Act
Civilians Injured Abroad
Defense Base Act FAQs
Injured Safety Officers
Safety Officer Benefits
Permanent Disability
Workers’ Compensation
Death Benefits
Disability Retirement
Articles
Workers Compensation
Social Security Disability
Longshore Workers Comp
Injured Safety Officers
Disability Retirement
Defense Base Act
Contact
FREE CONSULTATION
Menu
CLIENT WORK INJURY REPORT
CLIENT WORK INJURY REPORT
Date
Mr. / Mrs. / Ms.
First Name
Last Name
Address
City
State
Zip
Home Phone
Cell Phone
Other Phone
Email Address
Preferred Contact
Date of Birth
Social Security #
Union/Local
Name of Spouse
Who Referred You to Us?
(Name/Phone #)
EMERGENCY CONTACT - If we’re unable to reach you at your home address and phone number listed above:
Name
Relationship
Phone #
Address
City
State
Zip
INJURY INFORMATION
Employer
Date Began w/ Employer
Job Title
Job Duties
Employer Address
City
State
Zip
Regular Rate of Pay
If Pay Varies Specify
How much did you earn the year before your injury (W-2)
For each work injury, list the date, part of body hurt, and a brief description of how you were hurt:
Date
Body Part(s)
How Injured
Date
Body Part(s)
How Injured
Date
Body Part(s)
How Injured
Dates Off Work
Are You Working Now?
Yes
No
If yes, same job/duties/pay?
Yes
No
If now working modified/light duty or a different job, describe the job and duties
Current pay if less than before injury
Please find a recent piece of correspondence (if any) & complete the following about the insurance carrier:
Name of Workers' Comp Insurance
Claim Number
Claims Adjuster
Insurance Co. Address
City
State
Zip
Prior Injuries and/or Settlements
Had an Attorney or Currently Represented By
When
Claim Reported
Yes
No
DWC1 Claim Filed
Yes
No
Claim Accepted
Yes
No
90 Day Notice, If Denied, When:
Why
FOR LONGSHORE: Has the claim been controverted? If yes, we need a copy of the notice.
Yes
No
Any WCAB Hearings or Awards?
Yes
No
Which WCAB
Currently Treating
Yes
No
Last Saw
Next Appt.
P&S'd
Yes
No
QME Offered
Yes
No
Selected QME
Yes
No
Have you received any money from Workers’ Compensation?
Yes
No
If yes, rate paid
Date began
If ended, when
Have you received disability payments other than workers’ compensation?
Yes
No
State Disability
Private Insurance/LTD
Other
Rates and date paid:
Additional InformationPlease provide us with anything additional regarding your work injury that you need us to know.
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):
Name
Dates Treated
Address
Phone #
Which Injury
What Treatment
Name
Dates Treated
Address
Phone #
Which Injury
What Treatment
Name
Dates Treated
Address
Phone #
Which Injury
What Treatment
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.
Describe Injury / Condition
Date Began
Surgery
Yes
No
When
Describe
Name of doctor / facility
Address
Phone #
Current Symptoms
Yes
No
Describe
Describe Injury / Condition
Date Began
Surgery
Yes
No
When
Describe
Name of doctor / facility
Address
Phone #
Current Symptoms
Yes
No
Describe
Describe Injury / Condition
Date Began
Surgery
Yes
No
When
Describe
Name of doctor / facility
Address
Phone #
Current Symptoms
Yes
No
Describe
If you are human, leave this field blank.
Submit
Scroll to top
