Workers’ Compensation Intake Form

Workers Compensation Intake Form

Name

First and Last

Address

Phone

Preferred Method of Contact

Phone

Employer

Insurance Company for the Employer

Date of Injury

Description of Injury

How did the injury occur?

Has the injury been reported to the Workers Compensation Board?

Have you filed a WC Claim yet? (yes/no)

Has there been a controversion filed?

Has there been an Independant Medical Examination (IME)?

Your doctors' Name and Address (Please list all doctors involved along with their addresses)

Do you have all of your medical records?

Have you reached Medical Stability?

Have you had a Permanent Partial Impairment (PPI) Rating?

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