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: *Required fields.
Contact Information
Title:* Please make a selection.
First name:* First name is required.
Last name:* Last name is required.
City:* City is required.
State:* State is required.
Daytime phone:* Phone is required.
Mobile phone:
Email address:* Email is required.
Referral Source
How did you find us? Please check all that apply:
Saw ad in the phone book
Internet search (Dex Online)
Better Business Bureau (BBB)
Client of ours
About Your Injury
Date of your injury (mm/dd/yyyy)* Date of injury is required.  
What body part(s) did you injure? (neck, back, arm, etc.)* Pleae describe your injury.  
How were you injured?  
Have you ever injured these part(s) before?*

If yes, please describe the previous injury:

Please make a selection.
Are you receiving workers' compensation benefits checks? Yes 
Was receiving checks, but they have stopped.
Are your medical bills getting paid? Yes 
Bills were being paid, but they have stopped.
Please list all doctors who have treated you for your current work injury:  
What medical treatment are you currently receiving?  
Employment & Claim Information
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 
Was a claim filed with the Division of Workers' Compensation?Click to see a workers' claim for compensation form. Yes 
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 one you've received:
General Admission
Final Admission
Date of Admission (mm/dd/yyyy):

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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