Call Now For A Free Case Evaluation(908) 923-0020

Client Portal
Pezzano Law Group

Registration for Work Injury Claims

Work Accident

Names/Addresses/Job Title of any witnesses to the accident:

Workers’ Compensation Insurance Carrier

Wages before Taxes:

Dates Out of Work:

Dates Worked Light Duty:

Dates Paid by WC:

Periods Out of Work and Not Paid:

Injuries Sustained

Medical Treatment

Treatment Received

Physical Therapy

Prior or Subsequent Injuries

Dates of Prior/Subsequent Accidents:

General Description of Treatment Received:

Names and addresses of prior/subsequent physicians:

Prior Lawsuits or Workers’ Compensation Awards:

I understand that the answers I provide will be used to prepare my case, and if I am not completely honest, it will negatively affect the results of my case.

Thank you. Your form has been submitted