*Full legal name:
Address:
Date of Birth:
*Phone:
*Email Address:
Describe your injury:
Date, Time & Place of Injury:
How were you injured?
Please set out your injuries in detail:
Did you require an ambulance? If yes, which ambulance service did you use & which hospital were you taken to?:
Who is your primary doctor and roughly what are your medical expenses to date?:
Were there any witnesses at the scene?:
At the time of injury, were you in the course of employment? If so, name & address of employer:
If you have missed work, please list the dates off:
If Work Related:
When was the last date you were paid work comp weekly benefits for this injury?:
What was the last amount of the weekly benefit payment?:
Employer's work comp insurance company:
Name of work comp adjuster & Claim#:
State the doctors, hospitals, chiropractors, psychologists & physical therapist(s) that you have seen for this injury:
If you have health or disability insurance, who is it with?:
Have you ever collected worker's compensation before?:
Who have you worked for in the past (who, when, and how long)?:
How far did you go in school (where attended) and if a diploma or GED received, what year:
If pursuing Social Security / Long Term Disability benefits:
Are you currently working? If no what date did you last work & why did that work end?:
If you have a physical or mental impairment, please describe:
Please indicate if you have applied for:
Social Security Benefits	Long Term Disability Benefits
Has your long-term disability carrier threatened to cut off benefits?:
When was the last denial or decision made?:
If you are pursuing long-term disability benefits, please state the name and address of the insurer: