Case Assessment Questionnaire

Please take a moment to fill out and submit this questionnaire so that we may assess your case and provide you with our opinion concerning possible actions to address unresolved issues with your claim.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of injury or illness

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Claim Number
Provide a brief description of injury or illness (example; area of injury):

0/300
Were you granted a Non-Economic Loss award (NEL) for your injury or illness?
If yes, what is the percentage of your NEL award?
If your NEL award is 60% or higher, is your claim with the Serious Injury Program?
Have you had a NEL Redetermination?
Section 1. About Return-to-Work Services
Were you able to return to your pre-accident job?
If no, were you provided with Work Reintegration Services?
If yes, was a Suitable Occupation (SO) identified?
Were you successful in obtaining employment in your SO?
Section 2. Loss of Earnings Benefits (LOE)
Do you currently receive LOE benefits?
If yes, are you receiving Full LOE or Partial LOE?
Has the WSIB conducted your Final LOE Review, also referred to as the 72-Month Lock-in Review?
If you answered yes, what was the date of your Final LOE Review?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was your LOE benefit reduced or stopped at the Final LOE Review ?
If your LOE was reduced or stopped, please provide the reason(s) the WSIB gave you to reduce or stop your LOE benefits at the 72-month Lock-in review.

0/300
Did you appeal the WSIB's decision to reduce or stop your LOE benefit?
Section 3. Appeals
Are you currently appealing any other decisions made in your claim?
Select from below the issue(s) being appealed
Enter N/A if there are no issues under appeal
Select from below the current appeal stage
What is the status of your appeal if it's at the WSIB's Appeal Services Division?
Date of decision being appealed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provide a brief description of your concerns regarding your claim.

0/500
Please upload any decisions made in your claim by a WSIB Appeals Resolution Officer (ARO), or if applicable, the Workplace Safety & Insurance Appeals Tribunal, or the WSIAT decision number.

Cancelof
Section 4. Benefits From Other Insurance Plans or Providers
Did you apply for Canada Pension Disability (CPPD)? If yes, were you approved
Please check the benefits you currently receive or applied for from other insurance plans
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Should be Empty:

Section 1. About Return-to-Work Services

Section 2. Loss of Earnings Benefits (LOE)

Section 3. Appeals

Section 4. Benefits From Other Insurance Plans or Providers