WORKER’S COMPENSATION INTERVIEW FORM
Name________________ Date_________ Referred by_________________
Address___________________ Home Phone____________ DOB________
Race _______ Spouses Name _________________ Dependant_________
Date of Marriage___________________ Place Married_________________
Employer_______________________________How Long?____________
Address____________________________ Work Phone_______________
Average Weekly Wage__________________
Insurance Carrier_________________________ Adjuster_____________
Address____________________________________________________
Carrier’s Attorney Phone_______________________________________
Firm Name and Address________________________________________
Date of Injury ________________________________
Location____________________________________
Job Description_______________________________
What was injured______________________________
How did it occur______________________________
Witnesses: Name _____________________ Name____________________
Address ________________________Address______________________
City/State/Zip_____________________________________
Date employer notified_____________ Name of person notified__________
What is his/her position with company __________________Phone______
Who was/is your immediate supervisor?_________________ Phone______
Date disability began____________ Ended______________
Nature and extent of disability____________________________________
____________________________________________________________
When will you be able to return to work_____________________________
Attorney Specific Forms
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