Workers Compensation - Part 1 - Personal Background

General Information:

Name:

First Last

Phone Number:

Maiden Name:

First Last

Social Security Number:

Date of Birth:

Place of Birth:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer:

Referred by:

Date of Injury:

Marital History:

Name:

First Last

Maiden Name:

First Last

Phone Number:

Date of Birth:

Place of Birth:

Date of Marriage:

Place of Marriage:

Occupation:

Spouse's Employer:

Previous Marriage(s):

Spouse Name:

Date of Marriage:

Date/Place of Divorce or Spouse's Death:

Place of Marriage:

Children:

Name:

Date of Birth:

Address:

Child Support:

Do you currently pay child support?

How much is your current monthly child support obligation?

Do you owe any outstanding child support?

Sort Term and Long Term Disability:

Have you ever applied for short term or long term disability as a result of your work related injury?

Long Term Disability insurance company:

Short Term Disability insurance company:

Did your employer pay any portion of the premium for your long/short term disability insurance:

Employment History:

At the time of accident:

Employer:

Phone Number:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

When were you first employed:

Job title or type of work:

Immediate supervisor:

Hours per week regularly worked:

Rate of pay:

Reason for termination:

(If applicable)

Employment History:

As a result of the accident:

Inclusive dates unable to work:

Did you experience any difficulty in performing job when you returned?

Explain:

Employment History:

Since the accident:

Did you experience an increase or decrease of pay:

Explain:

Have you changed employers:

Employer:

Phone Number:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

When were you first employed:

Job title or type of work:

Immediate supervisor:

Hours per week regularly worked:

Rate of pay:

Reason for termination:

(If applicable)

Employment for the past ten years:

Employer:

From/To:

Job:

Reason for leaving:

Earnings from last year prior to the accident:

Under what name and where:

Who prepared your tax returns:

Activities:

List below what normal activities you enjoyed before this accident:

Sports, hobbies, etc.

List all of your usual activites you have not been able to perform, or can only perform with difficulty since the accident:

Climbing stairs, ironing, cutting grass, dancing, lifting children, etc.

How long were you fully disabled:

In case of housewife, how long before able to do housework:

(Provide dates)

Education History:

List all schools attended and training courses taken, including those in the military:

Name of School:

Address (as near as you can recall):

Diploma, Certificate, etc. (List type):

Dates attended:

Date diploma, certificate received:

Prior Claims:

Have you ever filed a claim of lawsuit for personal injuries:

(Vehicle accident, etc.)

Please describe the claim, listing the name(s) of the other parties involved, approximate date of injury, nature of the injury, and how each claim was resolved:

Have you ever filed claims for the following:

Unemployment

Civil Rights

Social Security Disability

Medicare/Medicaid

Title XIX

Other

Unemployment:

Date of Application:

Benefits?

Civil Rights:

Date of Application:

Benefits?

Social Security Disability:

Date of Application:

Benefits?

Medicare/Medicaid:

Date of Application:

Benefits?

Title XIX:

Date of Application:

Benefits?

Other:

Please Describe:

Date of Application:

Benefits?

Criminal History:

Have you ever been arrested or convicted of a felony?:

Please answer the following:

Date:

Nature of the charge/conviction:

Court:

Disposition:

Workers Compensation – Part 1 – Personal Background

General Information:

Marital History:

Child Support:

Sort Term and Long Term Disability:

Employment History:

Employment History:

Employment History:

Activities:

Education History:

Military Information:

Prior Claims:

Have you ever filed claims for the following:

Criminal History: