New Client Information Form
Please Enter "N/A" for Fields that do not Pertain to You!
Email address *
Have you already spoken to someone in our office? *
How did you hear about us? *
Today's Date *
MM
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WCB # For This Case *
Full Name *
Social Security Number *
Street Address *
City *
ZIP *
Home Phone *
Cell Phone
Fax
Email Address *
Would you prefer to be contacted by: *
Gender *
Date of Birth *
MM
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DD
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Relationship Status *
Do you speak English? *
Highest degree of education? *
Vocational Training
Employer When Injured *
Employer Phone Number *
Your Work Address *
Date Hired *
MM
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DD
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YYYY
What Local do you belong to? If none, answer N/A. *
Your Supervisor's Name *
Job Title/Description *
What types of activities do you normally perform at work? *
Was Your Job (Check One) *
Required
What was your gross pay (before taxes) per pay period? *
Did you receive lodging or tips in addition to your pay? *
[1] Did you work for another employer at the time of the accident or illness? *
[1] If yes, please provide the name of the company:
[1] Is yes, did you lose time?
Clear selection
[1] If yes, Address of Company
[1] If yes, what was your gross pay (before taxes) per pay period?
Your Injury or Illness
Date of Injury or Date of Onset of Illness *
MM
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DD
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YYYY
Time of Injury *
Please specify AM or PM
Time
:
Where did the injury/illness happen? *
Was this your usual work location? *
How did the injury happen? *
List Your Injuries *
[2] Was the injury the result of the use or operation of a motor vehicle? *
[2] If yes, who's vehicle was it?
Please include license plate number and whether or not there was a police report.
Have you given your employer or supervisor notice of injury/illness? *
Notice was given to: *
Notice was given: *
Date Notice was Given *
MM
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DD
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YYYY
Did anyone see your injury happen? *
Yes or No. If yes, please list names.
Return to Work
Did you stop work due to your injury/illness? *
Yes or No. If yes, on what date?
Have you returned to work? *
Yes or No. If yes, on what date? Who is your employer? And what is your gross pay now?
Did your employer pay you for any lost time? *
Yes or No. If yes, how much?
Medical Treatment for this Injury
What was the date of your first treatment? *
MM
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DD
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YYYY
Where did you first receive treatment? *
Name, Address, Phone & Fax of the Doctor(s) Treating you for this Injury or Illness *
List any other Accident or Illness to same Body Part(s) *
WCB# for 2nd Claim *
If none, enter NOT APPLICABLE
Insurance Carrier Case Number for 2nd Claim *
If none, enter NOT APPLICABLE
Compensation Insurance Information
Name of Insurance Carrier *
Carrier Case # *
Name of Claims Adjuster *
Phone Number *
Fax Number *
Is the insurance carrier paying you? *
Yes or No. If yes, how much?
Additional Injury History
Is another attorney presently working on this claim? *
List any prior or pending Worker's Compensation Claims *
If none, enter Not Applicable
List any personal injury or no-fault law-suits *
If none, enter Not Applicable
List any prior or subsequent non-work related injury(ies) *
If none, enter Not Applicable
Name(s) of Doctor(s) that treat/treated for such unrelated injuries *
If none, enter Not Applicable
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