Toff's Law

Worker’s Compensation Client Intake

Please fill out the form as completely as possible and email it to our office so that we can review your information, determine the issues in your case, provide you with some legal counseling and decide whether or not we can represent you. If you prefer, you can write your answers on a separate piece of paper and mail or fax it to us.

Contact Information

1. Your Name
2. Phone
3. Alternate Phone
4. Email
5. Date of Birth
6. Referred by

Accident Information

1. Date of Accident
2. Job Title
3. Employer
4. Date of Hire
5. Weekly wages
6. Facts of injury
7. Parts of Body Injured
8. Primary treating physician/s
9. Describe Current Pain & Limitations
10. Describe all prior injuries, symptoms or treatment to the same body parts as your work injury & give dates.
11. Have you seen a panel QME doctor? If Yes, who evaluated you and when? What did the QME say?
12. List all dates off work due to this injury and what benefits you received.
13. List all prior workers’ comp claims and describe injuries and how claims were resolved.
14. Provide any additional information you feel is important.

 

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