Workers Compensation Intake WORKER’S COMPENSATION INTERVIEW FORM Intake Date Refferal Name Age Address City State Zip Telephone Social Security # Date of birth Email Date of Injury EMPLOYMENT AT TIME OF INJURY Job Title Salary Hours per day and days per week Place of Employment Address Supervisor Telephone HOW INJURY OCCURRED DESCRIPTION OF INJURIES Are you still out of work due to injuries? Return Date Has injury been reported to IC? By Whom Date Ever received any WC Benefits? Amount WHY ARE YOU SEEKING HELP FROM A LAWYER? (WHAT BENEFITS DO YOU THINK YOU AREN’T GETTING, OR WHAT HAS DEVELOPED IN THE CASE THAT MAKES YOU WANT LEGAL ADVICE?) DOCTORS OR MEDICAL FACILITIES CONTACTED/FROM WHOM REFERRAL HAS RECEIVED TREATMENT: (TYPE OF FACILITY/ NAME, PHYSICIAN, ADDRESS/PHONE) Any potential third party liability? Potential Defendant? Any other claims made? Unemployment/ Social Security/ Disability Discrimination Attorney handling these claims?