Case Assessment Questionnaire

Please complete this questionnaire to help LegalPro Connect understand your WSIB matter and identify a potential referral to a licensed lawyer or paralegal in our Preferred Legal Provider network. Your answers will help prepare a factual summary for a prospective provider’s review. LegalPro Connect does not provide legal advice or determine the merits of your case. Submitting this questionnaire does not mean a provider has accepted your case or preserve objection or appeal rights.
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 (if known)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Claim Number
Briefly describe your workplace injury or illness.

Describe it in your own words. You do not need to provide a diagnosis or detailed medical history at this stage.0/300
What would you like help with regarding your WSIB claim?

Briefly describe your main concern and the help you are seeking from a lawyer or paralegal. If you are unsure, describe what has happened in your own words.0/2000
Has WSIB granted you a Non-Economic Loss (NEL) award for this injury or illness?
What NEL percentage did WSIB assign?
Enter the percentage shown in your WSIB decision, if known. Leave blank if you are unsure.
Has WSIB told you that your claim is in the Serious Injury Program?
Has WSIB reassessed your NEL percentage since the original award?
Section 1. About Return-to-Work Services
Have you returned to the job you held before your injury or illness?
Has WSIB provided return-to-work services for this claim?
Your letters may call these work reintegration or work transition services.
Has WSIB identified a Suitable Occupation (SO) for you?
Have you worked in the Suitable Occupation identified by WSIB?
Section 2. Loss of Earnings Benefits (LOE)
Are you currently receiving Loss of Earnings (LOE) benefits from WSIB?
What type of LOE benefits are you currently receiving?
Has WSIB told you that it completed a final review of your Loss of Earnings (LOE) benefits?
What is the date on WSIB’s final LOE review decision letter?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter the date printed on the decision letter, if available. Leave blank if you are unsure.
What did WSIB’s final LOE review decision say about your benefits?
What reasons did WSIB give in its final LOE review decision?

Copy the relevant wording from the decision letter, if available. If you describe it in your own words, please say so. Leave blank if you are unsure.0/2000
Have you submitted an objection or appeal concerning your LOE benefits?
Section 3. Appeals
Have you submitted an objection or appeal about any WSIB issue other than LOE benefits?
Which WSIB issue or issues have you objected to or appealed?
Select all issues you have objected to or appealed. If you are unsure which category applies, select “Not sure.”
Where is your objection or appeal currently being handled? Where is your objection or appeal currently being handled? Select all that apply. If unsure, select “Not sure.”
What is the current status of your WSIB objection or appeal? Select all that apply if you have more than one.
What is the date on the decision letter concerning the issue you want help with?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter the date printed on the relevant decision letter. Leave blank if you do not have a letter or are unsure of the date.
Upload the decision letter or correspondence related to the issue you want help with (optional).

If available, upload the complete letter, including any page showing a deadline. You can submit this questionnaire without uploading a document.
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Does your letter state a deadline? If so, copy the wording and date here.
Copy the exact sentence about the deadline, if available. Do not calculate a date. If you are unsure, write “Not sure.” Submitting this questionnaire does not preserve objection or appeal rights.
Section 4. Benefits From Other Insurance Plans or Providers
Have you applied for Canada Pension Plan disability benefits (CPP disability)?
Which other benefits have you applied for or received?
Select all that apply. Select “None” or “Not sure” only if you are not selecting another option.
Do you currently have someone representing you in this WSIB matter?
LegalPro Connect

LegalProConnect
Consent to referral and information sharing
Requesting a referral does not mean a lawyer or paralegal has accepted your case. Applicable fees and payment terms are set out in the LegalPro Connect and provider agreements completed during the referral process. Submitting this questionnaire does not preserve objection or appeal rights.
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