DO I HAVE A CLAIM?
Have you been injured at work? Have you had to miss work due to an injury that occurred at work. Have you lost wages due to missing work because of an injury that occurred at work? Do you have medical bills that were the result of an injury sustained at work? If you answered yes to any of these questions you may be eligible for workers compensation benefits. Please fill out the form below so we can inform you of your eligibility for compensation benefits.
INJURY INFORMATION FOR
| Injury Information | |||||
| In what state did the injury occur? | |||||
| Injury Description | |||||
| How where you injured? | |||||
| Physician Information | |||||
| Name: | |||||
| Address: | |||||
| City: | State: Zip: |
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| Tests Performed: | |||||
| Was the injury reported to your employer? | Yes No |
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| Employer Information | |||||
| Name: | |||||
| Address: | |||||
| City: | State: Zip: |
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| Job Title: | |||||
| Years of Employment: | Injury Date: | ||||
| Personal Information | |||||
| Name: | |||||
| E-mail: | |||||
| Address: | |||||
| City: | State: Zip: |
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| Home Phone Number: |
Work Phone Number: |
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| SS Number: |
Birthday: |
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