Workers' Compensation On Line Intake Form
Please provide the following contact information:
How were you referred to the office?
Enter the date of your industrial injury:
Enter your date of birth:
Describe how you were injured:
Describe your injuries:
Please indicate time missed from work:
Does it appear that you will not be able to return to the same job that you were doing at the time of the injury? If so, please explain why not:
Describe any gaps in your treatment:
Enter the date of the last treatment paid for by your employer's workers' compensation insurance:
Enter the date of the last temporary disability check paid by your employer's workers' compensation insurance:
Please provide the following contact information about your employer:
Name Title Organization Street Address Address (cont.) City State/Province Zip/Postal Code Country Work Phone Home Phone FAX
Please provide the following contact information regarding your employer's workers' compensation insurance:
Name Title Organization Street Address Address (cont.) City State/Province Zip/Postal Code Country Work Phone FAX
Please indicate whether your claim been accepted or denied?
Please indicate whether or not you have been represented by an attorney on this case before?
Describe any prior claim or similar injuries:
