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Let's Start Your Free Workers' Compensation Claim Evaluation
Were you injured on the job?
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Have you been treated by a doctor for your injuries?
*
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Yes
No
Do you already have legal representation for your workers' compensation Claim?
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Injury Date
Month / Day / Year
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Have you reported your injury?
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Yes
No
When were you hired?
Month / Day / Year
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Are you still employed with the same employer?
*
Yes
No
Date Terminated
Month / Day / Year
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Day
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Year
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2025
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2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2003
2002
2001
2000
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1998
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1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
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1938
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1933
1932
1931
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Business / Company Name
Manager or superior's Name
First
Last
Employer's Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Employer's Phone Number
Please select your injury below:
(check all that apply)
Back Injury
Muscle Sprain/ Tear
Cuts, Lacerations, Puncture Wounds
Broken/Fractured Bones
Bruises/Contusions
Hernia
Car/Truck Accident
Slip and Fall
Other
Please describe your injury in details.
Your Name
*
Your First Name
Your Last Name
Email
*
We'll send you a copy of this report and our contact details.
Your phone number
*
Please double check your phone number before submitting the form.
How can we help you?
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Comments, questions, concerns, etc.
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