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Do I have a worker’s compensation case?
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?
Have you received authorized medical treatment from the workers' compensation insurance carrier or TPA?
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:
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