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Job Title
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How much do you make per hour?
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How many hours do you work each week?
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Gross weekly income before taxes:
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Employer Name
*
Employer Address
*
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Do you currently have an attorney?
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Date of Accident
*
Date Format: MM slash DD slash YYYY
Did you provide notice of accident to employer within 30 days of incident?
*
Yes
No
Type of Injury (body parts, diagnosis if you know)
*
Surgery?
Yes
No
Mentioned by Doctor
Treatment Status
*
Still Treating
Finished Treating
Not Sure
Employment Status
*
Off with Injuries
Back to Work Full-Duty
Back to Work Light-Duty
Fired
Quit
Other
Virginia Only: Under an Award?
Yes
No
Unsure
Not VA Selection
North Carolina Only: Claim accepted under a Form 60 or 63?
Yes
No
Unsure
Currently Receiving Comp Checks?
Yes
No
If you answered yes to receiving Comp Checks, what is your weekly amount?
Have you filed a Claim Form?
Yes
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If you answered yes to filing a claim, what is the status?
Accepted
Denied
Claim Being Investigated
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