Workers' Compensation Case Evaluation-Short Form

We can evaluate your case if:

Title


First Name

Last Name

Address

City

State / Zip

You will need to enter either a phone number or e-mail address so that we can contact you.

Date of injury

Employer


Are you currently employed?
yes no
Has the Insurance Carrier sent you an Admission of Liability? (Requires Acrobat Reader to view)
yes no
If yes, please select:
General Admission of Liability was filed
Final Admission of Liability was filed: Date of Admission:
Injury(s)

Was a claim filed with Division of Workers' Compensation? (Requires Acrobat Reader to view)
yes no not sure
Are you receiving worker's compensation benefits checks?
yes no was receiving checks, but they have stopped
Are your medical bills getting paid?
yes no insurance company was paying, but has stopped
Doctors seen for workers' compensation injury

What medical treatment are you currently receiving?
(please check all that apply)
no current treatment
injections
surgical evaluation
recent surgery
psychological counseling
physical therapy
massage therapy
chiropractic treatment
feldenkrais
other
Why did you decide to contact an attorney?

Please give us any additional information that you feel
will help us evaluate your case

Security Question:

What letter has the gavel behind it?

Hit "Submit" and we will review your case. Someone from our office will contact you.