Workers' Compensation Form

First Name*

Last Name*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Cell Phone Number*

Email Address*

Name of Employer

Date of Birth (mm/dd/yy)

Date of Injury (mm/dd/yy)

Address of workers' compensation insurance company

Claim number (or TPA if known) of workers’ compensation insurance company

How accident happened (Be specific as to how the injury occurred. For example “I slipped on grease while making a delivery and fell directly onto my right knee cap, causing a fracture.”) If applicable, describe the type occupational exposure or repetitive stress causing injury.

Has your claim been accepted by the workers’ compensation carrier?

Yes
No

Have you received authorized medical treatment from the workers' compensation insurance carrier or TPA?

Yes
No

If yes, provide the name and address of your main authorized treating physician

What parts of your body do you claim were injured? (Use diagnosis where appropriate. For example, head trauma/concussion, herniated L5-S1 unoperated, fractured right arm, etc.)

Best time to schedule an appointment

How you are most easily contacted

Workers’ Compensation Form

Workers Compensation Case