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Workers' Compensation Questionnaire

Name
Mailing Address  
      Street Address
      City 
      State
      Zip
E-Mail Address
Phone Numbers
Name of Employer
Where Injury Happened
Date of Injury
Type of Injury
e.g. hurt lifting, fell, hand caught in machine, breathing chemicals, etc
Details of Injury
please include as much relevant information as possible, e.g. I needed surgery for ______, describe other medical treatment and expenses, I missed __ months of work, I am able (or not able) to return to my old job, etc.
Are wage loss and medical benefits currently being paid? Yes    No

Explain
When to call & further contact information
 
 

 
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