Worker's Compensation
Staff Member Intaking:
*
LO
BB
LA
MM
TW
SC
TC
TA
Caller Name (if not injured party):
Caller Phone Number:
Caller Email:
Relationship Of Caller To The Injured:
Potential client Info
Full Name Of Potential Client
*
Prefix
*
Mr.
Ms.
Phone
*
Email
No Email Provided
No Email
Date of birth
Address
Street Address
City
State
Country
Country
Postal code
How Did You Hear About Us
*
Billboard
Driving By
Building
Word Of Mouth
Facebook
Google
Referral
TV
Website
Other
Prior Client
If other, where did you hear about us?
Okay To Text?
*
Yes
No
Okay To Email?
*
Yes
No
Have You Consulted With Any Other Law Firms?
Yes
No
If Yes, who?
If Yes, Are You Currently Represented By An Attorney For This Matter?
Yes
No
If Yes, Who Currently Represents you?
If we are not able to assist, may we send your information to a referral source?
*
Yes
No
EMPLOYER/INSURER INFORMATION:
Employer’s Name:
Position of Employment:
Rate of Pay:
Hours Worked per Week:
FACTS OF INCIDENT:
Date of Injury:
Location of Injury:
Time of Injury:
Describe How Injury Occurred:
Reported to Employer?
Yes
No
INJURIES AND MEDICAL TREATMENT:
List ALL Injuries:
Were you transported by ambulance?
Yes
No
Were you evaluated in ER on date of crash?
Yes
No
Medical Treatment Received:
Are you still receiving treatment?
Yes
No
If yes, please describe ongoing treatment/future appointments:
WORKERS’ COMPENSATION BENEFITS | INSURANCE INFORMATION:
Workers’ Compensation Ins Company Name:
Claim number (if available):
DRUGS/ALCOHOL:
Was a drug test performed:
Yes
No
Results of Drug Test:
Positive
Negative
Unkown
Call Notes
General Notes During Intake:
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