1. Applicant’s Information
Applicant’s Name
*
Date of birth
*
Driver License/ ID no.
*
Address
Street Address
*
City
*
State
*
Country
*
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal Code
*
Phone
*
Email
*
Injury 1 date
Injury 1 time
Injury 2 date
Injury 2 time
Previously retained attorney for WC
Yes
No
Signed documents
Yes
No
Attorney's Name
Attorney's Address
Attorney's Phone
Medi-Cal
Yes
No
Medicare
Yes
No
Other Ins.
Yes
No
Insurance name
Policy Number
2. Employer At Time of Injury
Date of hire
Last day Worked
Employer’s name
Employer’s Address
Employer’s Telephone
Location of injury (if other than above)
Occupation/Job Title
Hourly Wage
$
Gross Weekly earnings at the time of injury
$
How Paid(Cash/check)
Pay Period (weekly, biweekly, monthly)
Other benefits
3. Injury I
Date of Injury I
Injury Reported?
Yes
No
Injury 1 Report Date
Injury 1 reported to whom?
Claim form provided for Injury 1
Yes
No
Were you able to continue working at the time of injury?
Yes
No
Are you working now?
Yes
No
Terminated?
Yes
No
Termination Date
Post termination
Last working day
Reason Given
Disabled?
Yes
No
4. Benefits Received
Has your employer continued your regular salary?
Yes
No
Weekly wages
$
Regular Salary from
Regular Salary Till
Has Insurance benefits been received?
Yes
No
Insurance Rate
$
Insurance Received From
Insurance Received Till
Has State Disability Benefits been received?
Yes
No
Benefit Rate
$
Benefit Received From
Benefit Received Till
Has Unemployment Benefits been received?
Yes
No
Unemployment Benefits Rate
$
Unemployment Benefits From
Unemployment Benefits Till
5. Employer Insurance Information
Insurance Company name
Insurance Company Address
Insurance Company Phone
Claim Number
Adjuster
Other
6. Co-Insurance / TPA Information
Co-Insurance Company name
Co-Insurance Company Address
Co-Insurance Company Phone
Co-Insurance Claim Number
Co-Insurance Adjuster
Others
7. History of Injury
Explain in detail how Injury (1) occurred
List of Injured body parts
Responsible(s) for injury/ illness
Employer
Machine
Only Client
Fellow Employee
Chemical Substance (Fumes, Dust, Etc.)
Equipment
Unsafe condition
Someone Else
Other
8. Witnesses
To accident (Names, Position at Company Address, Phone Number)
Names of the People at work whom where aware of your injury
9. Medical Treatment
Was medical treatment provided?
Yes
No
Is treatment being provided by Employer?
Yes
No
Last day treated
Were you hospitalized?
Yes
No
Hospital Name
Hospital Address
Hospital Phone
10. Injury II
Date of Injury II
Injury Reported?
Yes
No
Injury 2 Report Date
Injury 2 reported to who?
Claim form provided for Injury 2
Yes
No
Were you able to continue working at the time of injury?
Yes
No
Are you working now?
Yes
No
Terminated?
Yes
No
Termination Date
Post termination
Last working day
Reason Given
Disabled?
Yes
No
11. Benefits Received II
Has your employer continued your regular salary after II?
Yes
No
Weekly wages
$
Regular Salary from
Regular Salary Till
Has Insurance benefits been received?
Yes
No
Insurance Rate
$
Insurance Received From
Insurance Received Till
Has State Disability Benefits been received?
Yes
No
Benefit Rate
$
Benefit Received From
Benefit Received Till
Has Unemployment Benefits been received?
Yes
No
Unemployment Benefits Rate
$
Unemployment Benefits From
Unemployment Benefits Till
12. Employer Insurance Information II
Insurance Company name II
Insurance Company Address II
Insurance Company Phone II
Claim Number II
Adjuster II
Other II
13. Co-Insurance / TPA Information II
Co-Insurance Company name II
Co-Insurance Company Address II
Co-Insurance Company Phone II
Co-Insurance Claim Number II
Co-Insurance Adjuster II
Others II
14. History of Injury II
Explain in detail how Injury (2) occurred
List of Injured body parts in Injury II
Responsible(s) for injury II / illness
Employer
Machine
Only Client
Fellow Employee
Chemical Substance (Fumes, Dust, Etc.)
Equipment
Unsafe condition
Someone Else
Other
15. Witnesses II
To accident II (Names, Position at Company Address, Phone Number)
Names of the People at work whom where aware of your injury II
16. Medical Treatment II
Was medical treatment provided for Injury II?
Yes
No
Is treatment being provided by Employer?
Yes
No
Last day treated
Were you hospitalized?
Yes
No
Hospital Name
Hospital Address
Hospital Phone
17. PRIOR INJURIES/CONDITIONS
Are there any prior work-related injuries for the same employer?
Yes
No
Any work related injuries for a prior employer?
Yes
No
Date
Body Parts Claimed
Filed Claimed?
Yes
No
Pending or Settled?
Pending
Settled
Settled Date
How much?
$
Are there any prior accidents NOT work related?
Yes
No
Type of accident
i.e. vehicular, slip and fall, sport injury
Date of prior accident
Effected body part list
Are there any illnesses NOT work related?
Yes
No
Type of ilness
Effected body part list
18. POSSIBLE RELATED CLAIMS
W.C / CIVIL CLAIM
132a Wrongful Termination
Serious and Willful
Sexual Harassment
Age Discrimination
Sexual Discrimination
Labor Dispute
FEHA (return to Work Issue)
Salary Disputes (Money Owed)
Wrongful Death
ADR – Unique
P.I
Third Party
Personal Injury
Premises Liability
MVA
OTHER CLAIMS
Social Security
Product (s) Liability
Description and date of related claim