1. Applicant’s Information
Applicant’s Name
*
Date of birth
*
Driver License/ ID no.
*
Address
Street Address
*
City
*
State
*
Country
*
Country
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