New Client Information Form

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Please Enter "N/A" for Fields that do not Pertain to You!

Email *

Have you already spoken to someone in our office? *

Yes

How did you hear about us? *

Today's Date *

YYYY

WCB # For This Case *

Full Name *

Social Security Number *

Street Address *

City *

ZIP *

Home Phone *

Cell Phone

Fax

Email Address *

Would you prefer to be contacted by: *

Mail

Phone

Gender *

Female

Male

Prefer not to say

Other:

Date of Birth *

YYYY

Relationship Status *

Do you speak English? *

Yes

Maybe

Highest degree of education? *

Vocational Training

Employer Info

Name of Employer When Injured *

Employer Phone Number *

Your Work Address *

Job Title/Description *

What types of activities do you normally perform at work? *

Your Supervisor's Name *

Date Hired *

YYYY

What Local do you belong to? If none, answer N/A. *

Was Your Job (Check One) *

Full Time

Part Time

Seasonal

Volunteer

Other:

Required

What was your gross pay (before taxes) per pay period? *

Did you receive lodging or tips in addition to your pay? *

Yes

[1] Did you work for another employer at the time of the accident or illness? *

Yes

[1] If yes, please provide the name of the company:

[1] Is yes, did you lose time?

Yes

Clear selection

[1] If yes, Address of Company

[1] If yes, what was your gross pay (before taxes) per pay period?

Your Injury or Illness

Date of Injury or Date of Onset of Illness *

YYYY

Time of Injury *

Please specify AM or PM

Time

What were you doing when this happened? *

How did the injury happen? *

List any other Accident or Illness to same Body Part(s) *

Where did the injury/illness happen? *

Was this your usual work location? *

Yes

[2] Was the injury the result of the use or operation of a motor vehicle? *

Yes

[2] If yes, who's vehicle was it?

Please include license plate number and whether or not there was a police report.

List Your Injuries *

Have you given your employer or supervisor notice of injury/illness? *

Yes

Date Notice was Given *

YYYY

Notice was given to: *

Notice was given: *

Orally

In Writing

Did anyone see your injury happen? *

Yes or No. If yes, please list names.

Medical Treatment for this Injury

What was the date of your first treatment? *

YYYY

Where did you first receive treatment? *

Name, Address, Phone & Fax of the Doctor(s) Treating you for this Injury or Illness *

Are you still being treated? *

Yes

Return to Work

Did you stop work due to your injury/illness? *

Yes or No. If yes, on what date?

Have you returned to work? *

Yes or No. If yes, on what date? Who is your employer? And what is your gross pay now?

Did your employer pay you for any lost time? *

Yes or No. If yes, how much?

WCB# for 2nd Claim *

If none, enter NOT APPLICABLE

Insurance Carrier Case Number for 2nd Claim *

If none, enter NOT APPLICABLE

Compensation Insurance Information

Name of Insurance Carrier *

Carrier Case # *

Name of Claims Adjuster *

Phone Number *

Fax Number *

Is the insurance carrier paying you? *

Yes or No. If yes, how much?

Additional Injury History

Is another attorney presently working on this claim? *

Yes

List any prior or pending Worker's Compensation Claims *

If none, enter Not Applicable

List any personal injury or no-fault law-suits *

If none, enter Not Applicable

List any prior or subsequent non-work related injury(ies) *

If none, enter Not Applicable

Name(s) of Doctor(s) that treat/treated for such unrelated injuries *

If none, enter Not Applicable

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