Workers’ Compensation Interview Form

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

–For Attorney Specific Forms you can download in Word format, go to

http://www.uslegalforms.com/forattorneys/


Inside Workers’ Compensation Interview Form