Worker's Compensation

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

Postal code

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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