Troy & Eaton, LLP
Intake Form - for New Clients (If you have a C-3 form or a Notice of Indexing form from the NY Workers' Compensation Board please provide a copy to our office).
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Todays Date: *
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Name: *
Address
Email Address:
Telephone Number *
Date of Birth
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Employer at Time of Injury
How much were you earning per week at the time of your injury?
Are you currently being paid by an insurance company due to this injury?
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Date of Injury
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WCB Number (eight digit number assigned by the Workers Compensation Board)
Insurance Carrier (name and Address)
Brief Description of Injury
Did you file an accident report?
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If you filed an accident report, who was it with?
Body Parts Injured
Have you seen a doctor?
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What doctor did you see and when:
Do you have follow up appointments?
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Have you filed any Workers' Compensation Claims in the past and if so who represented you?
Please give a brief description of any issues you are currently having on your claim:
Have you lost any time from work due to this injury?
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How did you hear about our office?
Do you currently have an attorney, if yes please provide name and address?
I understand that filling out this form does not create an Attorney/Client relationship between myself and Troy & Eaton,LLP. I also understand that prior to reviewing this matter I must provide Troy & Eaton, LLP an OC-110 form allowing them to review my case with the Workers' Compensation Board. *
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