Workers Compensation Information

* = required fields

* Name

Address

City

State

Zip

*Telephone


Employment Information

What is the name and address of the employer you were working for when the accident happened?

Date of injury or accident
Employer Name

Address

City

State

Who should we contact at your place of business?

Name

Phone

Do you know the name and address of the worker’s compensation insurance carrier?

Name

Address

If know, please provide a claim number

If know, please provide the name of your claims adjuster

Health insurance

Name of Health Insurance Company

Name of individual whose whole name is on the policy

Identification Number

Group Number

Attorney Information

Have you hired an attorney to help you in this matter?

If yes, please give name, address and phone:

Attorney Name

Attorney Address

Attorney City

Attorney State

Attorney Phone