Do I have a worker’s compensation case?

Name:*
Address:
Home Phone:
Cell Phone:
Email:*
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:
Comments
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