Workers’ Compensation Case Questionnaire Si usted habla Español por favor haga click en el botón de “Translate” en la esquina derecha de su pantalla y podrá leer nuestra página en Español. Personal InformationName* Prefix First Last Suffix Spouse Name Prefix First Last Suffix Date of Birth* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone Number (Main)*Phone Number (Alternate)Do you require an interpreter?*YesNoWhat language do you speak?*Nearest relative (or friend) not living with you: First Last Relationship of nearest relative (or friend):Address of nearest relative (or friend): Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have Medi-Cal?*YesNoEmployer InformationName of Employer*Employer's Phone NumberEmployer's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment InformationDate of Hire* Job Title*Salary/Hourly Rate of Pay*Please enter a value greater than or equal to 0.Number of hours per week?*Please enter a value greater than or equal to 0.Job Duties:* Have you been terminated/laid off from this job?*YesNoPlease explain the conditions of your termination:* Paid Overtime?*YesNoWere you paid 1 1/2 for overtime?*YesNoAre you a member of a Union?*YesNoWhat is the name of the Union?*Union Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you complete the Worker's Compensation Claim form and give it to your employer?*YesNoWorker's Compensation Claim Form DownloadWhat was the date you completed and submitted the claim form?* Did your employer answer (complete the bottom portion of the claim form) and return it to you?*YesNoDid you receive a copy of the completed claim form?*YesNoWhat date did you recieve the completed claim form?* If you are going to a doctor for this work injury, was the doctor selected by your employer?*I am not going to a doctor.Yes, my employer selected the doctor.No, my employer did not select the doctor.Was the doctor selected by you?*YesNoDo you have objections to changing to a doctor of our choice?*YesNoWere you advised of your employer/insurance co. medical provider network?*YesNoWere you advised of your right to choose your own doctor for work injuries?*YesNoOther EmployersDo you have a second job?*YesNoName of employer (second job):*If you are currently working, what day did you return to work? If you are not working, what was your last day of work? Other employers during the last year:Employer NameJob TitlePay RateHours Per Week Injury/Illness InformationType of injury/illness:*Have you ever consulted another attorney about this injury/illness?*YesNoName of other attorney:*Date of injury (or beginning date of illness)* Ending date of illness (if applicable) Address where injury occurred: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Time of injury: : HH MM AM PM Parts of body injured: How did the injury/illness occur?* Who is responsible for the injury/illness? (Please check all that apply) Employer Fellow Employee Unsafe Condition Machine Chemical Substance Someone Else Please explain the responsibility of any checked above. Medical Treatment for Injury/IllnessPlease list your current doctors.Doctor NameAddressPhoneLast Date SeenNature of Treatment Please list other doctors/hospitals you have seen for this injury/illness:NameAddressPhoneLast Date Seen Were you hospitalized overnight?*YesNoInsurance InformationName of Workers' Compensation Insurance Company:*Workers' Compensation Insurance Company Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Workers' Compensation Insurance Company Phone:Name of Claims Adjuster:Claim NumberHas your claim been denied?YesNoDate of Denial:* Do you have private medical insurance?*YesNoPrivate Medical Insurance Company Name:*Who paid for your treatment Workers' Compensation Insurance Private Medical insurance Medi-Cal Yourself Please list all medical bills paid by you and not yet reimbursed:DescriptionAmount Please list all unpaid medical bills:DescriptionAmount Information for Calculation of Disability BeneiftsPeriods you did not work due to injury or illness:Start DateEnd Date Periods you received Workers' Compensation Benefits:Start DateEnd Date Have you applied for State Disability?*YesNoBenefits received from other sources:SourceDatesAmount Include State Disability, Unemployment, Social Security, Long Term Disability, Retirement/Pension, or any other source of benefits.Other Injuries/IllnessesHave you ever had any other on-the-job injuries/illnesses?*YesNoAny prior workers' compensation claims?*YesNoPlease list prior workers' compensation claims:*DatesParts of BodyAre you fully recovered? Have you had any off-the-job injuries/illnesses?*YesNoPlease list off-the-job injuries/illnesses:*DatesParts of BodyAre you fully recovered? Please list any doctors/hospitals you have seen due to the above listed injuries/illnesses or workers' compenastion claims:DatesDoctor/HospitalAddress Have you ever filed a claim or lawsuit for a work injury or personal injury?*YesNoList other medical conditions: Heart disease, arthritis, etc.Please list any doctors/hospitals you have seen for the above medical conditions:DatesDoctor/HospitalAddress Terms And ConditionsAgreement* I have read, understand and agree to the Terms and Conditions