Free Online Workers Comp Case Evaluation

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Job Title*

How much do you make per hour?*

How many hours do you work each week?*

Gross weekly income before taxes:

$0.00

Employer Name*

Employer Address*

City State

Do you currently have an attorney?*

Date of Accident*

Did you provide notice of accident to employer within 30 days of incident?*

Type of Injury (body parts, diagnosis if you know)*

Surgery?

Treatment Status*

Employment Status*

Virginia Only: Under an Award?

North Carolina Only: Claim accepted under a Form 60 or 63?

Currently Receiving Comp Checks?

If you answered yes to receiving Comp Checks, what is your weekly amount?

Have you filed a Claim Form?

If you answered yes to filing a claim, what is the status?

Provide a brief description of the accident:*

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