Registration for Work Injury Claims

Work Accident

Name:*

Street Address:*

City:*

State:*

Zip:*

Spouse:

Email:*

Tel (H):

Tel (Cell):*

Emergency Contact (Name):

Tel:

Referred By:

DOB:

SS#:

Employer:

Employer Address:

Job Title / Occupation

Supervisor:

Accident Date:

Location of Accident:

Injury Reported to:

Date Injury Reported:

Describe How the Accident Occurred:

Do you believe the accident was caused by the negligence of another person or company? If so, why?

Was the person who caused the accident a co-worker? Yes No

Was a police report or incident report prepared? Yes No

Did your employer admit that the accident occurred? Yes No

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

Are you a Medicare Recipient? Yes No
If so please provide HIC#:

Are you a Medicaid Recipient? Yes No
If so please provide Id#:

Private Health Ins. Coverage? Yes No
Carrier Name: Member ID:

Did your health insurance carrier pay for any medical treatment related to the work accident? Yes No
(if yes, fill the following details)

Workers’ Compensation Insurance Carrier

Carrier Name:

Claim No:

Adjuster Name:

Adjuster Tel:

Nurse Case Mngr:

NCM Tel:

Did you provide the workers’ compensation carrier with a statement? Yes No

Date of Hire:

Is this a seasonal job? Yes No

If yes, how many months in a year do you general work?

Annual Salary: $

Hourly Rate of Pay At Time of Accident: $

Overtime? Yes No

Rate: $

Average Number of Hours worked per week (including O/T):

Were you paid for less hours than you actually worked?

Were you paid cash for any portion of your pay?

Did you clock in and out at start/end of day and lunchtime?

Were you paid the same salary every week?

Did you do work before/after shift that you weren’t paid for?

Was your paycheck for exactly 40 hours/week or 8 hours/day?

Wages before Taxes:

Weekly / Biweekly $

Any Bonuses/Commissions Paid? Yes No

Rate: $

Did you lose time from work as a result of your injuries? Yes No
(if yes, fill the following details)

Dates Out of Work:

Dates Worked Light Duty:

Were you paid by your employer for lost time from work? Yes No

- VACATION TIME? Yes No

- SICK TIME? Yes No

Were you paid by the WC carrier for lost time? Yes No

WC Rate Paid: $ per week / biweekly / monthly

Is this rate at least 70% of your average gross weekly wages? Yes No

Dates Paid by WC:

Periods Out of Work and Not Paid:

Did you apply for Social Security Disability? Yes No
(if yes, fill the following details)

When?

Name of SS Attorney:

Was your employment terminated after the accident? Yes No
(if yes, fill the following details)

Date of Termination:

Reason for Termination:

Injuries Sustained

What parts of your body did you injure? Check all that apply

Head Neck Back Internal Pulmonary Dental Vision Left shoulder Right shoulder

Left Arm Right Arm Left Hand Right Hand Left Leg Right Leg Left Foot Right Foot

Other:

What are your current physical complaints?

Do you have any current emotional/psychiatric complaints related to the accident or your injuries? Yes No

Current Medications Related to the Accident:

Medical Treatment

Was an ambulance called to the scene? Yes No
(if yes, fill the following details)

Date you first sought medical treatment:

List the names and addresses of all hospitals, physicians, and medical facilities from whom you received medical treatment:
(no need to provide addresses of hospitals)

Treatment Received

MRIs: Yes No Proposed

Type(s) of MRI and Dates:

EMGs: Yes No Proposed

Type of EMG and Dates:

Surgery: Yes No Proposed

Type of Surgery and Dates:

Physical Therapy

Number of Weeks:

Injections: Yes No Proposed

Number of Injections:

Explain the Nature of any Recommended Treatment Which was NOT Authorized by the Insurance Carrier:

Prior or Subsequent Injuries

Did you ever injure the same body parts before or after the work accident? Yes No

If yes, provide diagnosis:

Dates of Prior/Subsequent Accidents:

(1)

(2)

(3)

General Description of Treatment Received:

(1)

(2)

(3)

Prior MRI? Yes No

Approximate Date:

Prior Injections? Yes No

Approximate Date:

Prior Surgery? Yes No

Approximate Date:

Names and addresses of prior/subsequent physicians:

(1)

(2)

(3)

(4)

(5)

Did You Serve in the Military? Yes No

Dates of Deployment:

Were you Injured During Service? Yes No

Treated at VA for Work Injuries? Yes No

Other Pertinent Information:

Prior Lawsuits or Workers’ Compensation Awards:

(1) Approximate Date of Accident: Approximate Date/Year of Settlement: State Where Claim Filed: Description of Injury: Percentage of Disability: % Amount of Settlement: $ Name of Attorney:

(2) Approximate Date of Accident: Approximate Date/Year of Settlement: State Where Claim Filed: Description of Injury: Percentage of Disability: % Amount of Settlement: $ Name of Attorney:

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.

Your Name

Date

Thank you. Your form has been submitted

Submit

Registration for Work Injury Claims

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:

Physical Therapy

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.

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