Workers Compensation Intake

Full Name:

Email:

Date of Birth:

Age:

Address:

Cell Phone #:

Alternate Phone #:

Social Security #:

Gender:

Marital Status:

Spouse's Name:

Name and age of children if under 19:

Who is an alternate contact for you other than your spouse?

Phone number of Alternate Contact:

Email of Alternate Contact if known:

Relationship to Alternate Contact (i.e. - friend, cousin, sister, etc):

Who was your employer at the time of your injury?

Your Position or job title:

Phone:

Email:

Street Address:

Human Resource Officer or Supervisor?

Phone:

Email:

Address:

Facsimile:

Describe Incident (i.e. date, time, location, how it happened):

Describe Injuries and Treatment (i.e. date, time, location, how it happened):

Was your accident caused by a co-employee or some other individual (Important Questions)?

If yes, explain:

Was your accident caused because safety equipment was removed or otherwise modified?

If yes, explain:

Did you go to the Emergency Room?

If yes, where you taken by Ambulance?

Which ER did you receive treatment at?

Do you have health insurance (i.e - Blue Cross, Aetna, Medicare, Medicaid, etc.)?

If yes, what is the name of the company?

Did you report your injury to anyone?

If so, who did you report it to and what is their position?

Was there an "Accident Report" or "First Report of Injury" done?

Have you received any Weekly Checks since you have been injured?

Amount of Temporary Total Disability Benefits (TTDB) paid:

How much where you paid at the time of your injury?

How many hours per week did you work on average?

Were you sent to a worker's comp doctor?

If yes, who?

Do you have a General Treating Physician?

If yes, who?

Have you received other medical treatment?

If yes, where?

Have you been terminated or laid off from your employment with this employer?

If so, how were your fired or laid off?

Do you have short term or long term disability insurance?

If yes, which insurance company provides the disability insurance?

Have you had an FCE or Functional Capacity Evaluation done?

If yes, Who did it?

When was it done?

What did it say?

Have you communicated or talked with a case manager or case worker that goes to your doctor's appointments?

If so, who?

When is your next doctor's appointment?

What is the doctor's appointment for?

Have you given a recorded statement or written statement to anyone?

If yes who and when?

Are you currently taking medication?

If yes, what is type?

Where do you have this medication filled?

Do you have medical bills not paid by workers comp that are for the on-the-job injury?

If yes, do you know the total of these medical bills?

Are you on Social Security Disability or SSI?

If yes, what is the basis of your benefits?

If you are receiving SSI, do you understand a settlement may affect your benefits?

Have you had any surgeries prior to the accident?

If so, what where they for and when?

What other, if any medical problems did you have before the accident?

Were there any witnesses to the accident?

If yes, please provide their name and contact information:

Do you have any photographs or other recordings of the accident, scene, vehicles or any injuries incurred?

If yes, will you email a copy to trent@garmonlawfirm.com

Have you ever filed a lawsuit before?

If yes, where and against who?

Have you ever been arrested or charged with a crime?

If yes, what was the arrest or charge for?

How Did the Caller Hear of Us:

Please mail a COPY of your Driver's License, Social Security Card, Health Insurance Card and or other identifying car to : 255 South 8th Street, Gadsden, Alabama 35901

ACKOWLEDGEMENT OF CANDOR

 

Have you been completely honest in giving this intake?

Client:

Have you acknowledged to the terms of the Client-Attorney Agreement?

If no, do you understand that our firm does not represent you unless and until a Client-Attorney Agreement is agreed to.

Who completed this online intake?

First and Last Name of Person Completing Form: