WC and PI Questionnaire

Workman's Compensation (WC) and Personal Injury (PI) Questionnaire

Please complete this form to the best of your ability!
Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Subscriber Name
Subscriber SSN
Which type of case are you seeking treatment for?
Please complete the following questions if you are seeking treatment for a work-related injury, i.e. Workman's Compensation (WC)
Have you filed a WC claim or accident report with your employer?
If yes to the question above, when did you file?
Your Employer
Claim Number
Adjuster's Name
Adjuster's Phone #
(000) 000-0000Format: (000) 000-0000.
Adjuster's email
example@example.com
Please complete this section if you are seeking treatment for an injury that another party or individual is responsible for, i.e. Personal Injury (PI). This includes homeowner's insurance, school insurance, personal liability, etc.
Policy Holder (Responsible Party)
Insurance Company (Responsible Party)
Insurance Company Phone (Responsible Party)
Format: (000) 000-0000.
What was the date injury/accident occurred?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where did the accident occur?
Please give a description of the accident
Please give a brief description of your injuries incurred in the accident
Have you initiated any legal actions pertaining to the accident?
Attorney's Name
Attorney's Phone #
Format: (000) 000-0000.
Attorney's Fax #
Attorney's Address
Should be Empty: