{"id":5035,"date":"2020-09-30T16:01:03","date_gmt":"2020-09-30T20:01:03","guid":{"rendered":"https:\/\/joemillerinjurylaw.com\/?page_id=5035"},"modified":"2021-09-13T11:35:06","modified_gmt":"2021-09-13T15:35:06","slug":"free-workers-comp-case-eval","status":"publish","type":"page","link":"https:\/\/joemillerinjurylaw.com\/free-workers-comp-case-eval\/","title":{"rendered":"Free Online Workers Comp Case Evaluation"},"content":{"rendered":"<h3>Free Online Workers Comp Case Evaluation<\/h3>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_chrome gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_17' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_17'  action='\/wp-json\/wp\/v2\/pages\/5035' data-formid='17' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_17_33\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_33\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_17_33'>\n                            \n                            <span id='input_17_33_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.3' id='input_17_33_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_33_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_17_33_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.6' id='input_17_33_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_33_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_17_14\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_14\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_17_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_17_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_17_14_1' value=''    aria-required='true'    \/>\n                                        <label for='input_17_14_1' id='input_17_14_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_17_14_2_container' >\n                                        <input type='text' name='input_14.2' id='input_17_14_2' value=''     aria-required='false'   \/>\n                                        <label for='input_17_14_2' id='input_17_14_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_17_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_17_14_3' value=''    aria-required='true'    \/>\n                                    <label for='input_17_14_3' id='input_17_14_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_17_14_4_container' >\n                                        <select name='input_14.4' id='input_17_14_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_17_14_4' id='input_17_14_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_17_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_17_14_5' value=''    aria-required='true'    \/>\n                                    <label for='input_17_14_5' id='input_17_14_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_14.6' id='input_17_14_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_17_4\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_4\" ><label class='gfield_label gform-field-label' for='input_17_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_17_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_17_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_2\" ><label class='gfield_label gform-field-label' for='input_17_2'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_17_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_17_15\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_15\" ><label class='gfield_label gform-field-label' for='input_17_15'>Job Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_17_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_11\" class=\"gfield gfield--type-product gfield--input-type-price gfield_price gfield_price_17_11 gfield_product_17_11 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_11\" ><label class='gfield_label gform-field-label' for='input_17_11'>How much do you make per hour?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_11' id='input_17_11' type='text' value='' class='medium ginput_amount'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/li><li id=\"field_17_12\" class=\"gfield gfield--type-quantity gfield--input-type-number gfield_price gfield_price_17_11 gfield_quantity gfield_quantity_17_11 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_12\" ><label class='gfield_label gform-field-label' for='input_17_12'>How many hours do you work each week?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_17_12' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_17_13\" class=\"gfield gfield--type-total gfield_price gfield_price_17_ gfield_total gfield_total_17_ field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" data-js-reload=\"field_17_13\" ><label class='gfield_label gform-field-label' for='input_17_13'>Gross weekly income before taxes:<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_17'>$0.00<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_13' id='input_17_13' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_17_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_16\" ><label class='gfield_label gform-field-label' for='input_17_16'>Employer Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_17_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_17\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_17\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Employer Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address gform-grid-row' id='input_17_17' >\n                        <span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_17_17_3_container' >\n                                    <input type='text' name='input_17.3' id='input_17_17_3' value=''    aria-required='true'    \/>\n                                    <label for='input_17_17_3' id='input_17_17_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_17_17_4_container' >\n                                        <select name='input_17.4' id='input_17_17_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_17_17_4' id='input_17_17_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_17.6' id='input_17_17_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_17_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_19\" ><label class='gfield_label gform-field-label' >Do you currently have an attorney?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_19'>\n\t\t\t<li class='gchoice gchoice_17_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_17_19_0'    \/>\n\t\t\t\t<label for='choice_17_19_0' id='label_17_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_17_19_1'    \/>\n\t\t\t\t<label for='choice_17_19_1' id='label_17_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_20\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_20\" ><label class='gfield_label gform-field-label' for='input_17_20'>Date of Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_17_20' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_17_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_17_20_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_17_20' class='gform_hidden' value='https:\/\/joemillerinjurylaw.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_17_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_21\" ><label class='gfield_label gform-field-label' >Did you provide notice of accident to employer within 30 days of incident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_21'>\n\t\t\t<li class='gchoice gchoice_17_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_17_21_0'    \/>\n\t\t\t\t<label for='choice_17_21_0' id='label_17_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_17_21_1'    \/>\n\t\t\t\t<label for='choice_17_21_1' id='label_17_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_22\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_22\" ><label class='gfield_label gform-field-label' for='input_17_22'>Type of Injury (body parts, diagnosis if you know)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_17_22' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_17_23\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_23\" ><label class='gfield_label gform-field-label' >Surgery?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_23'>\n\t\t\t<li class='gchoice gchoice_17_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Yes'  id='choice_17_23_0'    \/>\n\t\t\t\t<label for='choice_17_23_0' id='label_17_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='No'  id='choice_17_23_1'    \/>\n\t\t\t\t<label for='choice_17_23_1' id='label_17_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='Mentioned by Doctor'  id='choice_17_23_2'    \/>\n\t\t\t\t<label for='choice_17_23_2' id='label_17_23_2' class='gform-field-label gform-field-label--type-inline'>Mentioned by Doctor<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_24\" ><label class='gfield_label gform-field-label' >Treatment Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_24'>\n\t\t\t<li class='gchoice gchoice_17_24_0'>\n\t\t\t\t<input name='input_24' type='radio' value='Still Treating'  id='choice_17_24_0'    \/>\n\t\t\t\t<label for='choice_17_24_0' id='label_17_24_0' class='gform-field-label gform-field-label--type-inline'>Still Treating<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_24_1'>\n\t\t\t\t<input name='input_24' type='radio' value='Finished Treating'  id='choice_17_24_1'    \/>\n\t\t\t\t<label for='choice_17_24_1' id='label_17_24_1' class='gform-field-label gform-field-label--type-inline'>Finished Treating<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_24_2'>\n\t\t\t\t<input name='input_24' type='radio' value='Not Sure'  id='choice_17_24_2'    \/>\n\t\t\t\t<label for='choice_17_24_2' id='label_17_24_2' class='gform-field-label gform-field-label--type-inline'>Not Sure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_25\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_25\" ><label class='gfield_label gform-field-label' for='input_17_25'>Employment Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_17_25' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Off with Injuries' >Off with Injuries<\/option><option value='Back to Work Full-Duty' >Back to Work Full-Duty<\/option><option value='Back to Work Light-Duty' >Back to Work Light-Duty<\/option><option value='Fired' >Fired<\/option><option value='Quit' >Quit<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_17_26\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_26\" ><label class='gfield_label gform-field-label' >Virginia Only: Under an Award?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_26'>\n\t\t\t<li class='gchoice gchoice_17_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_17_26_0'    \/>\n\t\t\t\t<label for='choice_17_26_0' id='label_17_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_17_26_1'    \/>\n\t\t\t\t<label for='choice_17_26_1' id='label_17_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_26_2'>\n\t\t\t\t<input name='input_26' type='radio' value='Unsure'  id='choice_17_26_2'    \/>\n\t\t\t\t<label for='choice_17_26_2' id='label_17_26_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_26_3'>\n\t\t\t\t<input name='input_26' type='radio' value='Not VA Selection'  id='choice_17_26_3'    \/>\n\t\t\t\t<label for='choice_17_26_3' id='label_17_26_3' class='gform-field-label gform-field-label--type-inline'>Not VA Selection<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_28\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_28\" ><label class='gfield_label gform-field-label' >North Carolina Only: Claim accepted under a Form 60 or 63?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_28'>\n\t\t\t<li class='gchoice gchoice_17_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_17_28_0'    \/>\n\t\t\t\t<label for='choice_17_28_0' id='label_17_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_17_28_1'    \/>\n\t\t\t\t<label for='choice_17_28_1' id='label_17_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_28_2'>\n\t\t\t\t<input name='input_28' type='radio' value='Unsure'  id='choice_17_28_2'    \/>\n\t\t\t\t<label for='choice_17_28_2' id='label_17_28_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_29\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_29\" ><label class='gfield_label gform-field-label' >Currently Receiving Comp Checks?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_29'>\n\t\t\t<li class='gchoice gchoice_17_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_17_29_0'    \/>\n\t\t\t\t<label for='choice_17_29_0' id='label_17_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_17_29_1'    \/>\n\t\t\t\t<label for='choice_17_29_1' id='label_17_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_30\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_30\" ><label class='gfield_label gform-field-label' for='input_17_30'>If you answered yes to receiving Comp Checks, what is your weekly amount?<\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_17_30' type='text' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_17_31\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_31\" ><label class='gfield_label gform-field-label' >Have you filed a Claim Form?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_31'>\n\t\t\t<li class='gchoice gchoice_17_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_17_31_0'    \/>\n\t\t\t\t<label for='choice_17_31_0' id='label_17_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_17_31_1'    \/>\n\t\t\t\t<label for='choice_17_31_1' id='label_17_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_32\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_32\" ><label class='gfield_label gform-field-label' for='input_17_32'>If you answered yes to filing a claim, what is the status?<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_17_32' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Accepted' >Accepted<\/option><option value='Denied' >Denied<\/option><option value='Claim Being Investigated' >Claim Being Investigated<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/li><li id=\"field_17_34\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_17_34\" ><label class='gfield_label gform-field-label' for='input_17_34'>Provide a brief description of the accident:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div 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