GENERAL INFORMATION

First Name

Last Name

Email *

Phone *

Address

City

State

Postal code *

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

Date of birth *

Social Security Number *

Please upload a photo of the client

PNG, GIF, JPEG or JPG

Please upload a copy of client’s drivers license/ID

PNG, GIF, JPEG or JPG

EMPLOYER INFORMATION

Name of company client was working for at time of injury:

Company Address

Company City

Company State

Company Zip

Name of Manage/Supervisor

Company Phone

INSURANCE INFO

Have you filed a claim with the above employer?

INSURANCE INFO

Name of Insurance company with whom claim has been filed

Insurance Company Address

Insurance Company City

Insurance Company State

Insurance Company Zip

Insurance Company Phone

Insurance adjuster’s full name if known

Claim number in known

OCCUPATION

Job Title

Date of Hire

Description of job duties/responsibilities

Approximate weekly wage

How are you paid?

What was your rate for above at the time of your injury?

Were you terminated?

OCCUPATION

Date Terminated

Terminated by (Employee Name)

Above person’s position/title

Reason you were given for being terminated

Last day worked

OCCUPATION

Do you work another job?

OCCUPATION

Job Title

Date of Hire

Description of job duties/responsibilities

Approximate weekly wage

How are you paid?

Were you terminated?

OCCUPATION

Date Terminated

Terminated by (Employee Name)

Above person’s position/title

Reason you were given for being terminated

Last day worked

OCCUPATION

Did you return to work?

Yes

No

Date returned to work

EMPLOYMENT QUESTIONNAIRE

Approximately how many employees performed similar jobs at the company?

On average, how many hours per day did you work?

On average, how many days per week did you work?