Name*
Email*
Phone*
Address*
Address Line 2
City*
State*
Zip*
Jurisdiction claim number
Date of accident and injury*
Injured part(s) or symptoms suffered (if an occupational exposure)*
Please describe any related consequences of your accident and injury
Location injury occurred*
Specific description of how your injury occurred*
Names of Any Witnesses to the Accident
When Did You First Report Your Injury?*
Name of your supervisor*
When did your supervisor find out?*
How did your supervisor find out?*
When have you received medical care for your work injury?*
Where have you received medical care for your work injury?*
How long have you worked for this employer?*
Looking back over the last year, with this employer:
What was your average wage?*
What number of hours did you work per week?*
When injured, were you working for any other employer?
If so, what was the employer's name?
If so, what were your job duties?
If you have had any previous workers' compensation claims, say when and provide the general details
Has an award already been entered in your case?YesNo
Was the insurer previously paying either your:Medical BillsWage Loss BenefitsNeither
What has happened following your accident that has caused you to seek legal representation?*
How did you hear about Thomas & Thomas Law?
