Injuryintake

New Client*

New ClientRepeat Customer
First Name*
Last Name*
Enter Your Home Address*

Street Address

Apartment Number (if any)

CityState

Zip Code
Gender*

MaleFemale
What's Your Cell Phone Number?*
Email*
example@example.com
Birth Date*

MonthDayYear
SS Number?*
WCB Number (if you know it)
Who referred you to us? (we would like to thank them)*
Date Of Accident?*

MonthDayYear
Date
When you were injured who did give notice to?*
On what day?*

MonthDayYear
Date
How did you report it?*

in writingverbally
Tell us who your employer is if he is not listed click add option*

NYS DOCCSNYC Health & Hospitals CorpNYCTANYC DOTNYCHANYC DOCNational GridNYCDEPACS / Dept Juvenile JusticeOther
At Which Facility Do You Work ?*

DOWNSTATE CORRECTIONALFISHKILL CORRECTIONALBEDFORD HILLS CORRECTIONALGREENHAVEN CORRECTIONALSING SINGOTISVILLEQueensBoroOther
Please Tell Us the Name of the Company That you work for*
Tell us the address of the company that you work for*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was your Job?*

Full TimePart TimeSeasonalVolunteerOther
What was your gross pay (before taxes) per pay period?*
How often were you paid?*
If Yes, please describe:*
2nd Employer name & Address of company:*
Please Check Off the Statement That Applies To You.*

I HAVE NOT lost time from work due to my injuryI am NOT WORKING due to injury and I HAVE NOT received workers comp checks or salaryI LOST TIME FROM WORK due to injury BUT HAVE RETURNED TO WORKI am NOT WORKING due to injury BUT I AM RECEIVING: Salary, Sick/Vacation or City GrantI am NOT WORKING due to injury BUT I AM RECEIVING: WORKERS COMP CHECKS FROM INSURANCE COMPANY
Enter the date that you began losing time from work
Specify time out of work*
What is your job Title?*
Where did the accident happen?*
What were you doing when you were injured?(ex: Working on a ladder)*
How'd the accident happen?*
Officer, what were you were doing when you suffered an injury?*

Responding to a Code TenSubduing an InmateInmate takedownComing to the aid of a fellow officerMaking my roundsBreaking up a fightOther
Covid-19 Officer, what were you were doing when you suffered an injury?

Performing the Duties of a Correctional Officer, which put me in contact with potentially infected inmates and staff.
Covid-19 How were you injured?

While performing my job duties, was exposed to Covid-19
Covid-19 What were you doing when you suffered injury?

Performing my Job duties
Covid-19 Select All Body Parts That You Injured

COVID-19 Exposure
How were you injured?*

Inmate assaulted me causing injuryCrush Injury involving heavy objectSlip and Fall on slippery substance causing injuryFell down the stairs causing injurySlipped and fell while running to the aid of a fellow officerFelt something pop while running to respond to a callI suffered an injury while breaking up a fight between inmatesOther
Select All Body Parts That You Injured*

BackNeckHead Trauma (Traumatic Brain Injury)Right ShoulderLeft ShoulderRight ForearmLeft ForearmRight ElbowLeft ElbowRight ArmLeft ArmRight LegLeft LegRight KneeLeft KneeRight HipLeft HipRight HandLeft HandRight WristLeft WristLeft FootRight FootLeft AnkleRight AnkleOther
If an object was involved in your accident enter it here: (ex: a ladder)
If there were witnesses, Please provide the names here:
Who owned the vehicle?*

Your VehicleEmployer's VehicleOther VehicleOther
Name & Address of Doctor that treated you the first time:*
Who is your current treating doctor?*
What Doctor performed the Surgery?*
What date did you have the surgery?
What body parts did you have the surgery on?*

NeckBackHead Trauma (Traumatic Brain Injury)Right ShoulderLeft ShoulderRight ForearmLeft ForearmRight ElbowLeft ElbowRight ArmLeft ArmRight LegLeft LegRight KneeLeft KneeRight HipRight HipRight HandLeft HandRight WristLeft WristRight FootLeft FootRight AnkleLeft AnkleOther
Which body parts from this case did you injure in a prior case?*

NeckBackHead Trauma (Traumatic Brain Injury)Right ShoulderLeft ShoulderRight ForearmLeft ForearmRight ElbowLeft ElbowRight ArmLeft ArmRight LegLeft LegRight KneeLeft KneeRight HipLeft HipRight HandLeft HandRight WristLeft WristRight FootLeft FootRight AnkleLeft AnkleOther
What doctor treated you?*
Besides this comp case, are you suing anybody due to this accident?*

YesNoI did not know whether I can sue and would like advice regarding this
What is the name of the party that you are suing?
Who is your attorney that is handling the personal injury claim?
What is the name and address of the firm that you are leaving?
Signature*

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