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| *Last Name: |
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| Address: |
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| Home Phone: |
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| Work Phone: |
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| *E-mail Address: |
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| What time of day would you like us to call? |
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No Preference
Daytime
Evening |
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I. General Incident Information |
| Date you were injured. |
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| City and state incident occurred. |
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| Who was your employer when you were injured? |
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| What was your job title when you were injured? |
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| Briefly describe your job duties. |
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| Briefly explain events that caused your injuries. |
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| Briefly describe your injuries. |
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| Are any of the injuries substantiated by diagnostic tests, and if so, which tests? |
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| Did you report your injury to any supervisor or other person at the job within 120 days of the injury? |
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Yes No |
| If the answer to the last question was yes, when and to whom did you report your injury? |
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| If the answer to the last question is no, why not? |
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| Are you still under the care of a doctor? |
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Yes No |
| Provide the name and address of the doctor treating you for the injuries you sustained on the job. |
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| Are you currently working? |
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Yes No |
| Are you currently receiving workers compensation benefits? |
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Yes No |
| Was your injury accepted as a compensable claim? |
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Yes No |
| Before your injury, what was your monthly gross income? |
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II. Legal and Insurance Issues |
| Have you contacted any other lawyer about your potential claim? |
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Yes No |
| If you contacted another lawyer, did the lawyer agree to represent you? |
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Yes No |
| If you contacted another lawyer, is that lawyer currently representing you? |
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Yes No |
| If the lawyer is not currently representing you, please tell us the circumstances under which your relationship with that lawyer terminated. |
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| Have you negotiated with any insurance company or any other person in connection with this claim? |
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Yes No |
| If you answered yes to the previous question, are negotiations still ongoing? |
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Yes No |
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III. Legal Disclaimer |
| I agree that by submitting this information for evaluation, I will not be charged for the initial response. I further understand and agree that the above does not constitute a request for legal advice and that I am not forming an attorney-client relationship by submitting this information for evaluation. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter. |
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