| First Name |
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| Middle Name |
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| Last Name |
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| Company Name |
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| Address Line 1 |
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| Address Line 2 |
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| City |
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| State |
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| Zip Code |
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| Daytime Phone |
() - |
| Evening Phone |
() - |
| E-mail Address |
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| Date of Birth |
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| How did you find our web site? |
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| Are you currently collecting Workers Compensation? |
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| If so, how much are you receiving per week? |
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| name of your employer? |
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| How much did you earn per week? |
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| Name of your workers compensation carrier? |
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| Date of your injury? |
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| Nature of your injuries? |
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| Where did you get hurt? |
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| Are you still working? |
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| If not, are you disabled as a result of this injury, or for some other reason? |
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| If still working; are you working at your regular job or modified duty? |
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| If modified duty, how does it compare with regular job? |
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| If still working, are you making the same or less than before injury ( i.e. no overtime as a result of injury? ) |
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| Have you been to the hospital? if so, where? |
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| Names of doctors who have treated you? |
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| Did your employer have a list of doctors posted at work? |
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| Do you have a copy of the List of Doctors? |
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| Do you have private Insurance such as Blue Cross or an HMO? |
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| Do you have a Family Doctor who can evaluate your injuries? |
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| Did you sign a verification form acknowledging that you were advised of your rights ? |
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| Was a Notice of Compenstation Payable issued by Ins Co? |
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| Was a Notice of Temporary Compensation Filed? |
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| If Temporary Notice, when was it issued, has it been Stopped? |
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| If Receieved a Notice stopping Temporary Compensation, how long after your last check was receeived was it sent |
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| Have you been injured before? |
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| if so, please describe injuries and circumstances? |
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| Any prior workers compensation claims? |
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| Did you have an attorney? If so who was prior attorney? |
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| Status of prior claim? |
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| Do you have an attorney for your current claim? |
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| Is there any litigation pending in your current case? If so who is the WC Judge? |
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| What is the status of your current case? |
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| Have you signed any forms such as a Supplemental Agreement or Final Receipt? |
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| Have you received a Notification of Suspension or Modification? |
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| Is it still within 20 days since you receieved the Notification? Do you agree with it? |
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| Any additional information ? |
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