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? *
Your answer
Today's Date *
MM
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WCB # For This Case *
Your answer
Full Name *
Your answer
Social Security Number *
Your answer
Street Address *
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City *
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ZIP *
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Home Phone *
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Cell Phone
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Fax
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Email Address *
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Would you prefer to be contacted by: *
Gender *
Date of Birth *
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Relationship Status *
Do you speak English? *
Highest degree of education? *
Vocational Training
Your answer
Employer When Injured *
Your answer
Employer Phone Number *
Your answer
Your Work Address *
Your answer
Date Hired *
MM
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DD
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What Local do you belong to? If none, answer N/A. *
Your answer
Your Supervisor's Name *
Your answer
Job Title/Description *
Your answer
What types of activities do you normally perform at work? *
Your answer
Was Your Job (Check One) *
Required
What was your gross pay (before taxes) per pay period? *
Your answer
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:
Your answer
[1] Is yes, did you lose time?
[1] If yes, Address of Company
Your answer
[1] If yes, what was your gross pay (before taxes) per pay period?
Your answer
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? *
Your answer
Was this your usual work location? *
How did the injury happen? *
Your answer
List Your Injuries *
Your answer
[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.
Your answer
Have you given your employer or supervisor notice of injury/illness? *
Notice was given to: *
Your answer
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.
Your answer
Return to Work
Did you stop work due to your injury/illness? *
Yes or No. If yes, on what date?
Your answer
Have you returned to work? *
Yes or No. If yes, on what date? Who is your employer? And what is your gross pay now?
Your answer
Did your employer pay you for any lost time? *
Yes or No. If yes, how much?
Your answer
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? *
Your answer
Name, Address, Phone & Fax of the Doctor(s) Treating you for this Injury or Illness *
Your answer
List any other Accident or Illness to same Body Part(s) *
Your answer
WCB# for 2nd Claim *
If none, enter NOT APPLICABLE
Your answer
Insurance Carrier Case Number for 2nd Claim *
If none, enter NOT APPLICABLE
Your answer
Compensation Insurance Information
Name of Insurance Carrier *
Your answer
Carrier Case # *
Your answer
Name of Claims Adjuster *
Your answer
Phone Number *
Your answer
Fax Number *
Your answer
Is the insurance carrier paying you? *
Yes or No. If yes, how much?
Your answer
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
Your answer
List any personal injury or no-fault law-suits *
If none, enter Not Applicable
Your answer
List any prior or subsequent non-work related injury(ies) *
If none, enter Not Applicable
Your answer
Name(s) of Doctor(s) that treat/treated for such unrelated injuries *
If none, enter Not Applicable
Your answer
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