Colorado Springs

Toll-Free in Colorado
719-632-4808
800-975-8367
Colorado Workers' Comp. Case Evaluation
SiteLockWe can evaluate your case if:
  • You were injured in Colorado, or
  • The company you work for is based in Colorado.
What to know before you fill out the form:
  • It will take about 10-15 minutes to complete this form, and the information you send us is confidential.
  • No attorney-client relationship is established by submitting this form.
*Required fields.
Contact Information
Title:*
First name:*
Last name:*
Address:
City:*
State:*
Zip:
Daytime phone:*
Mobile phone:
E-mail address:*
Referral Source
How did you find us? Please check all that apply:
Saw ad in the phone book
Search engine
Findlaw.com
Dexknows.com (Dex Online)
Facebook
LinkedIn
Client of ours
Other
Employment & Claim Information
Employer:
Your job title:
How long have you worked for this employer?
Have you missed any work because of your injury?Click to see information about time missed from work. Yes  No

If yes, how much work have you missed?

Have you returned to work since you were injured? Yes  No

If yes, have you returned to work full-duty?
Yes  No
Did you report your injury(s) to your supervisor? Yes  No
Was a claim filed with the Division of Workers' Compensation?Click to see a workers' claim for compensation form. Yes  No  Not sure
Insurance carrier:
Have you received an Admission of Liability?Click to see an admission of liability. Yes  No

If yes, please select the most recent you've received:
General Admission
Final Admission
Date of Admission (mm/dd/yyyy):

About Your Injury
Date of your injury (mm/dd/yyyy)*
What body part(s) did you injure? (neck, back, arm, etc.)*
How were you injured?
Are you receiving workers' compensation benefits checks? Yes  No  Was receiving checks, but they have stopped.
Are your medical bills getting paid? Yes  No  Bills were being paid, but they have stopped.
Please list all doctors who have treated you for your work injury:
What medical treatment are you current receiving?
Additional Information
Why did you decide to contact an attorney?
Please give us any additional information that you feel will help us better evaluate your case:
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