Workers Compensation Intake

Workers Compensation Intake Form

Your Name (required)

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Fax Number

Your Email (required)

Additional Notes

Date of Birth

List all doctors you have seen in the last 5 years

Date of Injury

Give a brief description of how your injury occurred

Employer Name

Employer Address

Job Title

Date of Hire

Wages at time of injury

Hours worked per week

Body parts affected

Date reported to employer

Reported to whom

Did you receive a claim form?

When did you return it to employer?

Did your employer send it to a doctor?

When?

Name of Doctor you were sent?

Address of Doctor

Workers Comp Insurance Company

Workers Comp Insurance Address

Workers Comp Insurance Phone #

Claim #

Adjuster

Are you receiving benefits from the insurance company?

Are you receiving benefits from State Disability?

Who is your treating physician?

Were you fired or discriminated against?

Was anyone else responsible for your injury?

Were you injured due to faulty equipment?

Are you now, or have you been represented by an attorney for this injury

*Please remember that this information will be kept 100% confidential. No information will be submitted or released to any individual or business except Penney and Associates and its affiliates. Please be aware, however, that the firm does not accept all matters referred to it, and that no attorney-client relationship will be created simply because a message was sent to us. "Pay Nothing unless we collect" only applies to personal injury cases.