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LAW OFFICES OF RICHARD PENA P.C.
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Personal Injury
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Compensacion Laboral (Worker's Compensation)
Heridas Personales (Personal Injury)
Accidentes en el Trabajo (On the Job Inquiries)
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Admisíon de Compensación Laboral
On The Job Injuries
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Workers' Comp Intake
Workers' Compensation Intake
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Today's Date
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Language
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Name
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First
Last
Primary Phone #
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Type
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Cell
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Secondary Phone #
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Type
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Email
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Address
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City
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Zip Code
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Initial Interview Type
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In Office
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Date Of Injury
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What parts of your body are injured?
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Facts of the Injury
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Numbness/Tingling in arms/legs?
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Yes
No
Date of 1st Doctor's Visit after Injury
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Date of most recent Doctor's Visit
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Does a Doctor have you:
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Off Duty
Light Duty
Regular Duty
Which Medical Procedures have you had done? (select all that apply)
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Surgery
Injections
Physical Therapy
Is a Doctor reccommending any of the above?
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Surgery
Injections
Physical Therapy
Name of Treating Doctor
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Are you satisfied with your Treating Doctor?
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No
Employer
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Date of Hire
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Employer's Address
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Line 1
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City
State
Zip Code
Country
Does the Employer have WC Insurance?
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Select One
Yes
No
If yes, Carrier Name:
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Is the Insurance Carrier disputing the claim?
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Yes
No
If yes, explain why:
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Date claim was disputed
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NON - SUBSCRIBER:
Explain why someone else is at fault:
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TIBS: Temporary Income Benefits
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Select One
Currently Recieving
Recieved in the Past
Never Received
TIB Check Amount ($)
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Date TIBS Cutoff
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IIBS: Impairment income benefits
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Currently Receiving
Recieved in the past
Never Recieved
IIB Check Amount ($)
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Date IIBS Cuttoff
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If received TIBS or IIBS, did the employer provide Health Insurance that was stopped?
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Yes
No
Date it stopped:
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Were you receiving any benefits that have been terminated? examples: mileage, hotels, food
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Yes
No
Average Weekly Wage on DOI (before taxes)
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Did you have a 2nd Job on DOI
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Yes
No
Have you been Terminated?
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Yes
No
If terminated, explain why:
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Have you been placed at MMI?
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Yes
No
What type of Dr. placed you at MMI?
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Select One
DD / State Dr.
Treating Dr. / Reffered Dr.
MMI Date
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If placed at MMI, Did you dispute w/in 90 days?
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Yes
No
Have you had any treatment after being placed at MMI?
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Yes
No
If yes, what treatment?
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Did you notice improvement with the treatment?
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Yes
No
Have you been given an Impairment Rating (IR)?
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Yes
No
If yes, what % was given?
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What type of Dr. gave you the IR?
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DD / State Dr.
Treating Dr. / Reffered Dr.
Why are you seeking an Attorney?
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Additional Info
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How did you find us? (If other Atty referred put name of Law Firm)
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