Worker's Compensation Initial Interview Form

Background Information

First name: MI: Last name:

Maiden name, former names and/or aliases:

Address:

City: State: Zip:

Home Phone: Work Phone:

*Email Address:   

Other means of contact:

Marital status: Single Married Divorced

Spouse's full name, if any:

Number of children living at home under age 18:

Date of Birth: / /

Current age: Height: Weight @ Date of Accident: Current Weight:

Nationality:

Military backround (if any) (bring in your DD214):

Do you have any child support obligations whatsoever (past or current)? Yes No

If yes, are you delinquent in any of these child support obligations? Yes No


Employer Information

Employer at time of injury:

Address:

City: State: Zip:

Phone:

Position or bid job: Supervisor or Foreman:

Date employment began: / / Date last worked: / /

Salary/Hourly wage rate: $


Worker's Compensation Insurance Carrier Information

Insurer name:

Address:

City: State: Zip:

Phone:

Adjuster:

Have you been paid any weekly benefits? Yes No

If so, state the weekly amount: $ Date of last payment: / /


Personal Health Insurance Carrier Information

Insurer name:

Address:

City: State: Zip:

Phone:

Has this carrier paid any bills to date for this injury? Yes No


Injury Information

Date of injury: / /

If more than one date of injury, please list the other date(s) here:

Description of injury (Body part(s) injured):

How did the injury occur?

Witnesses (i.e., co-workers, foreman, workers for other companies...) (Please include name, address, and phone number):

Witness 1:

First name: MI: Last name:

Address:

City: State: Zip:

Phone:

Witness 2:

First name: MI: Last name:

Address:

City: State: Zip:

Phone:

Witness 3:

First name: MI: Last name:

Address:

City: State: Zip:

Phone:

Did you notify your employer of your injury either orally or in writing? Yes No

If so, on what date? / /

Nature and extent of permanent disability (if already known):

Nature and extent of permanent disability or permanent restrictions from any Prior physical or mental injuries or due to your general health:


Treatment of Current Injury

Medical providers (Please list names/addresses of doctors, therapists AND hospitals, if possible):

1. Name: Address:

2. Name: Address:

3. Name: Address:

4. Name: Address:

5. Name: Address:

6. Name: Address:

7. Name: Address:

8. Name: Address:

Outstanding medical expenses (i.e. pharmacy, mileage, doctors,...) (Who owed and amount):

1. Name: Amount:

2. Name: Amount:

3. Name: Amount:

4. Name: Amount:

5. Name: Amount:

Additional comments (If any):


Additional Information

To aid in the location of important records

Place of birth:

Former/Past residences from current residence backwards in time:

1.

2.

3.

4.

5.


Vocational Information

Please state the school names, dates attended, location and last grade completed.

Elementary School(s)

Junior High/High School(s)

Date graduated: / /

GED: Yes No Date: / / Location:

Vocational, military and/or further training after high school, if any:


Medical History

Past physical and mental medical treatment unrelated to your work injury (all old injuries, even appendix, tonsils, gallbladder, etc.), names and addresses if possible:

1. Treatment: Name: Address:

2. Treatment: Name: Address:

3. Treatment: Name: Address:

4. Treatment: Name: Address:

5. Treatment: Name: Address:

6. Treatment: Name: Address:

7. Treatment: Name: Address:

8. Treatment: Name: Address:


Second Injury Fund Information

Permanent injury with permanent activity restrictions due to a prior leg, arm or eye injury(s).

1. Date of first prior loss: / /

Nature and extent of prior injury/disability:

2. Date of second prior loss: / /

Nature and extent of prior injury/disability:


Third Party Information/Insurance

Was your accident caused by someone who did not work for the same employer?

Name:

Address:

City: State: Zip:

Phone:

Insurance carrier information:

Insurer:

Address:

City: State: Zip:

Phone:

Adjuster:


Miscellaneous

Are you receiving unemployment benefits/long term disability benefits? Yes No Amount

Were unemployment/long term disability benefits contested? Yes No

Short term or long term insurance carrier(s):

Name:

Address:

City: State: Zip:

Phone:

Claim #:

Have you given a verbal/written statement regarding this injury? Yes No

If so, to whom given, when given, etc.

Criminal record of convictions:


NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent. I agree that submitting this form does not create an attorney-client relationship and that the information I am providing may be used to check for conflicts of interest to determine if the firm can assist me with my legal inquiry.

*I Agree:   

*Please provide a copy of your health insurance card at your first appointment.

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