WORKMENS COMPENSATION INTAKE SHEET
I. CLIENT INFORMATION
a.
Name:
Name: FIRSTMIDDLE /MAIDENLASTb.Home Address
Home AddressStreet Address City State Zip
City State ZipCan letters and documents be sent to your home?
c.Telephone Numbers:
Telephone Numbers:1)Home: Area Code-XXX-XXXXCan you be contacted at home?
Can messages be left at home?
Phone Restrictions
2)Cellular: Area Code-XXX-XXXXd)Social Security Number
Social Security Number XXX-XX-XXXXe)Birth Date:
Birth Date: MM/ DD/ YYYY2.EMPLOYMENT INFORMATION
EMPLOYMENT INFORMATION Are you working? a.
Employer Name, Addressb.Job Title:
Job Title: c.Job Description: (Ploease describe what you must do at work, including all activities)
Job Description: (Ploease describe what you must do at work, including all activities)d.Number of Years at Current Employment:
Number of Years at Current Employment: e.How much were your average weekly wages did you earn weekly before you were hurt at work? $
How much were your average weekly wages did you earn weekly before you were hurt at work? $f.When was your last day of work?
When was your last day of work? MM/ DD/ YYYY g.Are you currenly represented in your Workmens Compensation Claim?
Are you currenly represented in your Workmens Compensation Claim? h.If so, who is your current attorney?
If so, who is your current attorney? Name/Address/Phone No.i.Who is your primary doctor?
Who is your primary doctor?Name/Address/Phone Numberj.If you cannot work, explain why not?
If you cannot work, explain why not?k.Are you a High School Graduate?
Are you a High School Graduate? l.Name of High School and Year of Graduatiion:
Name of High School and Year of Graduatiion: j.If you did not graduate High School, do you have a GED?
If you did not graduate High School, do you have a GED? k. What was the highest grade or level of education you completed?
l.. If you have a GED, when and where did you get it?
m.Have you had any further training or college?
Have you had any further training or college? n.If you have had further training or college, please describe it.
If you have had further training or college, please describe it.o. Please give a history of your past employment:
Please give a history of your past employment:3.CLAIM HISTORY
CLAIM HISTORYa.Have you ever filed a Social Security Disability/SSI claim or Personal Injury claim?
Have you ever filed a Social Security Disability/SSI claim or Personal Injury claim?b.What was the amount of recovery, if any, and name of attorney/law firm:
What was the amount of recovery, if any, and name of attorney/law firm: c.Do you have health insurance coverage?
Do you have health insurance coverage? d.Do you have State or private disability coverage?
Do you have State or private disability coverage? e.If you had pre-exisiting conditions before your job-related injury/disability, please let us know. Name the disabilities,
If you had pre-exisiting conditions before your job-related injury/disability, please let us know. Name the disabilities, describe them, and tell us what the names and addresses of the physicians who have records of them?f.What else do you think our attorneys should know about your claim?
What else do you think our attorneys should know about your claim?THANK YOU FOR TAKING THE TIME TO SEND US THIS INTAKE FORM.
By clicking the SUBMIT BUTTON below, you will transmit the information in this Intake form to the Dawson Law Firm, pllc. The information is only provided to familiarize the Firm with your situation to assist us in any discussions we may have with you regarding your issues and concerns. Nothing herein creates an attorney client relationship, although the contents shall remain confidential unless otherwise requested by the Visitor.
