NEW CLIENT - WORKERS' COMPENSATION

BACKGROUND

Please take your photo and upload it here. It will be saved to your case file.

Max. file size: 50 MB.

Please attach any pertinent documents to your claim such as most recent medical report, most recent correspondence from insurance carriers...etc. If you do not have these documents handy, please email to newclientinfo@ghitterman.com before your appointment.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Appointment Date and Time

How were you referred to us?

If you selected Friend/Family Member, Event, Attorney, Community Organization, or Other for the prior question, please specify where you heard about us.

Name

First Last

Address

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

Cell Phone/Home No.

Email Address

Date of Birth

SSN

Primary Language

Need Interpreter?

Do you have a smart phone?

Do you use texting?

Emergency contact (Name, Relationship, Cell Phone)

Employer at the time of your injury

Employer's address and phone

What is your job title?

Last day of work

If there is an insurance company that is handling your claim, please state the name, address, phone number, and claim number

If you have an adjustor that is assigned to your claim, please state the name, address, phone and email address

Name, address & phone number of each health care provider that you have seen for your work injury

Name, address, phone and email address for your family doctor

Do you have an attorney? If so, for how long and why are you seeking additional legal counsel?

INJURY

If your injury happened on a specific day, what was the date of your injury and how did it happen (if you have more than one specific injury, please list the date and how you were hurt on that date)?

Location (City) where injury occurred

Who did you tell at work that you were hurt and when did you tell them?

If your work injury happened over time, when did you first notice the onset of symptoms?

If your injury happened over time, please describe the job duties you believe contributed to your work injury

Please identify any and all body parts you believe are related to your work injury

Before your work injury, did you ever have problems/symptoms/treatment with any or all of the body parts involved in your work injury? [Please note that having a pre - existing condition does NOT disqualify you from receiving benefits] If yes, please describe the body part, the problems, symptoms and/or treatment for each body part

Please Indicate if you have ever had problems with the following conditions:

If you checked any of the above, please describe the problem and when it first started

Please describe any and all restrictions on your ability to work that existed before your work injury

EARNINGS

If you have missed time from work, when was the last day you performed work for your employer?

What were your wages on the day of injury?

$ per hour

Hours worked per week

Overtime

If you had a second job when you stopped working, please identify the name, address, and phone number of that employer

What wages did you earn in this second job?

If you have received money since you have been off work, how much are you receiving every two weeks and who is paying it?

If you have returned to work, what is the date you did so?

Workers' Compensation

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BACKGROUND

INJURY

EARNINGS