If you are ready to act, fill out the following information with as much detail as possible. The advantages of providing this information to our offices at this time is not only to allow us to get started and to ensure expeditious action, but also to preserve the evidence while it is fresh in your mind. At a later date, this will become crucial to your case and by recording it here, we can ensure its accuracy and completeness. This does not obligate you in any way, nor does it constitute a contract between the submitter and the Law Offices of Louis Roberts. All information submitted will be considered confidential.

NOTE: Making a false or fraudulent workers' compensation claim is a felony subject to up to five (5) years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.

 

YOUR INFORMATION

Name:
Address:
City:
State:
Zip:
Date of Birth:
Soc. Sec. #:
Email Address:

INJURY INFORMATION

Date of Injury:
Name of Employer :
Address of Employer:
City:
State:
Zip:
Employer's Workers Compensation Carrier:
Address of Carrier:
City:
State:
Zip:
Occupation at time of Injury:
Describe How Injury Occurred:
Did you Notify Employer?       When :
Whom did You Notify?
List all parts of your body that were injured:
What were your earnings at the time of the injury:
Hours per week worked:
If you received medical care, please list all providers:
1:
2:
3:
4:
If you were hospitalized, please provide name and address(es) below:
1:
2:
3:
Have you returned to work?       When :
Have you ever had any prior accidents? If so, state:


Date(s):
Body Part(s) Injured :
Name and Address of Doctor(s):

CURRENT WORK STATUS

Are you presently working?
Name and address of employer:
Describe your duties:

PRESENT MEDICAL STATUS

Please describe any disability or illness you presently have:


ADDITIONAL COMMENTS

If you have any other additional information or comments which may be relevant to your case, please include them below:

 

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