Case Assessment Questionnaire

1

Full Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

3

Address* This field is required.

Street Address

City

Province

Postal Code

Country

4

E-mail* This field is required.

example@example.com

5

Date of birth* This field is required.

Date

6

Date of injury or illness* This field is required.

Date

7

Claim Number* This field is required.This is required so that we can determine legislation in affect at the time of your injury or occupational disease

8

Provide a brief description of injury or illness (example; area of injury):* This field is required.

0/300

9

Were you granted a Non-Economic Loss award (NEL) for your injury or illness?* This field is required.

10

If yes, what is the percentage of your NEL award?

11

If your NEL award is 60% or higher, is your claim with the Serious Injury Program?* This field is required.

12

Have you had a NEL Redetermination?* This field is required.

13

Were you able to return to your pre-accident job?* This field is required.

14

If no, were you provided with Work Reintegration Services?

15

If yes, was a Suitable Occupation (SO) identified?

16

Were you successful in obtaining employment in your SO?

17

Do you currently receive LOE benefits?* This field is required.This ONLY applies to claims after December 31, 1997

18

If yes, are you receiving Full LOE or Partial LOE?* This field is required.

19

Has the WSIB conducted your Final LOE Review, also referred to as the 72-Month Lock-in Review?* This field is required.

20

If you answered yes, what was the date of your Final LOE Review?

Date

21

Was your LOE benefit reduced or stopped at the Final LOE Review ?* This field is required.

22

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

23

Did you appeal the WSIB's decision to reduce or stop your LOE benefit?* This field is required.

24

Are you currently appealing any other decisions made in your claim?* This field is required.

26

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.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

27

Did you apply for Canada Pension Disability (CPPD)? If yes, were you approved* This field is required.

28

Please check the benefits you currently receive or applied for from other insurance plansThis section allows us to determine if there are other insurance plans that you may eligible for

29

Provide a brief description of your concerns regarding your claim.

0/500

30

Terms and Conditions* This field is required.

31

WSIB Settlements