Workers' Compensation Consultation Intake

Intake Form

Workers' Compensation
Client Information
Full Legal Name*

First NameLast Name
Email Address*
example@example.com
PHONE NUMBER

Cell phone is preferred. By providing your cell phone number, you are giving us permission to contact you via text message.
Area Code*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Information
Marital Status:

SingleMarriedDivorcedWidow
Date of Birth

MonthDayYear
Date
Spouse's Name/Significant Other

First NameLast Name
Children's Names/Ages
Name of Emergency Contact

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Prior Criminal Record:

YesNo
If yes, please explain.
Incident Information
Date & Time of Incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Incident
City where Incident Occurred
State where Incident Occurred
How did the incident happen?
Witnesses
Investigated by Police?

YesNo
Report Number
Was your employer notified of your injury?

YesNo
Who from your employer was notified?

First NameLast Name
When was your employer notified?

MonthDayYear
Date
How was your employer notified?
Employer Information
Have you missed work as a result of this incident?

YesNo
Have you been paid for any of your time off work?

YesNo
Employer NameJob Title
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you were working for a TEMP AGENCY, provide their information below:

Temp Agency NameJob Title
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Wage Information

Enter your salary OR hourly wage information below to calculate your Average Weekly Wage
YEARLY SALARY
Type your yearly salary
Salary Average Weekly Wage Calculation
HOURLY RATE
Type your hourly pay rate
How many regular hours per week do you work?
Regular as opposed to overtime
How many MANDATORY overtime hours per week do you work?
Overtime must be mandatory and consistent to be considered part of your AWW.
What is your overtime pay rate?
If you normally make $10/hr. and overtime is 1.5x, then you would enter 15 in this field
Hourly Average Weekly Wage Calculation
Average Weekly Wage Estimator:
Injuries
Injuries Sustained in this Incident*
Prior Injuries
Additional Information Relating to your Injuries or Health
Your Health Insurance Information
Insurance Company
Policy Number
Group Number
Identification Number
Type of Coverage
e.g. PPO or HMO
Medicare?

YesNo
Medicare Number
Medicaid?

YesNo
Medicaid Number
Medical Treatment Information
Ambulance?

YesNo
Name of Ambulance Service
Emergency Room?

YesNo
Name of Emergency Room
Treating Physician
Workers' Compensation Insurance Information
Name of Workers' Compensation Insurance Company
Claim #
Adjuster's Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Are you currently represented by an attorney for this claim?

YesNo
Prior Injury Claims
How did you find us?*
e.g. Google, Avvo, Facebook, Yelp, Friend's Name, Attorney Referral Name
Other Important Information and Notes
File Upload - upload any file you think will be helpful to us in evaluating your claim (e.g. incident report, pictures, videos, medical records, etc.)

Cancelof
Should be Empty:

Intake Form

Client Information

Personal Information

Incident Information

Employer Information

Wage Information

Injuries

Your Health Insurance Information

Medical Treatment Information

Workers' Compensation Insurance Information