Workers Compensation Intake Questionnaire

CLARK and FEENEY
the train station, suite 106
1229 main street
lewiston, idaho 83501

Worker’s Compensation Questionnaire

Name:
Email:
D.O.B.:
S.S.N.#:
Date of Injury:
Location of Injury:
Employer:
Address of Employer:
Telephone Number of Employer:

 

Were there any witnesses to the accident?  Yes  No
If there were, please provide the name, address and telephone number below:

 

Name Address Telephone Number

 

Accident Information

In your own words, please briefly describe the accident/injury:

What were your injuries:

Who did you report the injury to:

Have you returned to work:  Yes  No   If so, what date: 

If not, have you received benefits in the form of payments for being unable to work?
 Yes  No

If you have, what amount $ 
How often are you receiving benefits? 

 

Medical Information

Please list all medical providers you have seen as a result of this accident/injury below:

Medical Care Provider City & State Provider Resides

Have you had surgery as a result of this injury/accident?  Yes  No

If so, at what facility?  Date of Surgery: 

Please list the medical care providers you have seen previous to this accident/injury within the past ten (10) years below:

Medical Care Provider City & State Provider Resides

What injuries still effect you (continuing symptoms)?

 

Loss of Income

Are you claiming a loss of income as a result of this accident/injury?  Yes  No

If yes, please provide information as to the following:

Dates missed from work: 

Wage per hour:  or Salary per month: 

With regard to missed hours, did you:

 Receive a reduction in pay for missed time;  Use vacation time;
 Use sick time; or  Use paid time off (PTO)

Explanation if necessary

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.

 

Changes in Lifestyle

Please describe in detail the activities you performed prior to the subject accident that you are no longer able to perform:

Please describe in detail how your injuries have changed your life:

With regard to missed hours, did you:

 Receive a reduction in pay for missed time;  Use vacation time;
 Use sick time; or  Use paid time off (PTO)

Explanation if necessary

Clark and Feeney will need a statement from your employer as to missed time from work for a claim in lost wages.