Workers’ compensation Intake
Thank you for contacting Chalk Law Office.
Please complete this brief intake form so we can evaluate your potential Workers’ Compensation claim. Completing this form does not create an attorney-client relationship.
If you need assistance in Spanish, please let us know.
Date
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Month
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Day
Year
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Referred by
Full Name (Mr./Mrs./Ms.)
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Address
*
Mailing Address (If different)
Home Phone
Cell Phone
*
Email Address
*
Primary Language
Date of Birth
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Month
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Day
Year
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Employer at Time of Injury
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Occupation
*
Job Duties
*
Workers’ Compensation Insurance Company (if known)
Claim Number
Date of Injury
*
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Month
-
Day
Year
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Body Parts Injured
*
How did the injury occur?
*
Earnings at Time of Injury
*
Last Day Worked
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Month
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Day
Year
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Claim Status
Accepted
Denied
Under Investigation
Are you receiving workers’ compensation disability benefits (temporary disability checks)?
Yes
No
Date of Last Payment
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Month
-
Day
Year
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Receiving State Disability (EDD) Benefits?
Yes
No
Are you receiving medical treatment for the work injury?
Yes
No
Date of Last Treatment
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Month
-
Day
Year
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Did MediCal pay for any treatment?
Yes
No
Previous Workers’ Compensation Claims?
Yes
No
Who is your regular treating doctor for this industrial injury?
Was someone other than your employer or coworkers responsible for your industrial accident?
Yes
No
Explanation (if someone else responsible)
Spoken to or hired another attorney regarding this injury?
Yes
No
Name of Other Attorney (if applicable)
Name (Print)
Date (Signature)
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Month
-
Day
Year
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Submit
Should be Empty: