subject_line
Worker's Compensation
Claimant Information
Claimant First Name
*
Claimant Last Name
*
Street Address
*
City
*
State
*
Zip Code
Phone Number
Date of Birth (mm/dd/yy)
SSN
Marital Status
Description of Claimant
0/300 characters
Photo available?
Yes
No
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Injury Information
Type of Injury
*
Date of Injury (mm/dd/yy)
*
Cause of Injury
Restrictions
Compensation
No
Yes
Amount
Amount
Medical Information
Doctor First Name
(Non IME)
Doctor Last Name
(Non-IME)
Street Address
City
State
Zip Code
Phone Number
Appointments
Medical Reports available?
Yes
No
Send it here...
IME Doctor First Name
IME Doctor Last Name
Street Address
City
State
Zip Code
Phone Number
Appointments
Employer Information
Company Name
*
Street Address
City
State
Zip Code
Shift
Length of Employment
Claimant's Position/Title
Employer Know of Investigation
Yes
No
Attorney Information
Attorney First Name
Attorney Last Name
Street Address
City
State
Zip Code
Authorization
Time/Amount Authorized:
*
Additional Comments
(this space provided to elaborate on details if needed)
0/500 characters
Additional attachments, send them here...
Client Information
Company
*
File #
Contact First Name
*
Contact Last Name
*
Street Address
City
State
Zip Code
Phone Number
*
Email Address
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