Full Name *
Spouse's Full Name * Address * City * State * Zip * Daytime Phone Number * Alternate Phone Number Email Address * Social Security Number Date of Birth Gender Male Female Name of relative or friend who will always know how to reach you
Relative / Friend Address Relative / Friend City Relative / Friend State Relative / Friend Zip Relative / Friend Phone How did you hear about The Galler Law Firm, LLC? EMPLOYER INFORMATION Employer's Name Employer's Address Employer's City Employer's State Employer's Zip Employer's Phone Number Name of your immediate supervisor Title of your immediate supervisor When did you begin working with this company? What was your job title at the time of accident? Describe your duties Are you a union member? Yes No If yes, what is the name of your union representative?
Phone number of your union representative
INSURANCE INFORMATION Workers' Compensation Insurancy Company Address City State
Zip Phone Number Name of adjuster ACCIDENT INFORMATION Date of accident Time of accident Location of accident (including county) Please describe in detail how the accident occurred Was your accident caused in whole or in part by carelessness or negligence of persons other than your fellow employees? If so, please explain: Was your accident caused in whole or part by the use of any piece of defective machinery or equipment? If so, please explain: If your injury was caused in whole or in part by defective machinery or equipment, there exists the possibility of a claim against the manufacturer, or other person(s) responsible for its condition. WITNESSES First Witness' Full Name Address City State Zip
Phone Number Second Witness' Full Name Address City State Zip Phone Number NOTICE
Did you give notice of injury to the company? Yes No Name of person to whom you gave notice Date you gave notice Give details of how you gave notice, including time, place, and witnesses WAGE INFORMATION Number of hours worked per day Number of hours worked per week How are your wages paid? Rate of pay per period (before tax deductions) If you receive tips, bonuses or commissions, how much did they average per week? If you have not worked for the company for 13 weeks prior to the accident, what was the average weekly pay for the other employees with the same job classification? Did your employer provide meals, uniforms, housing, transportation, or other fringe benefits? Yes No If yes, describe & estimate the weekly value LOST TIME When did you first lose time from your job due to your injury? Are you still off the job due to your injuries? Yes No If you returned to work for the same employer, list the period of time you were back at work and any decrease in your earnings If you are no longer working for the same employer, list the date you left and the reason for leaving If you are working for or have worked for another employer since your accident, state the period of time you were back at work, any decrease in your earnings; and the name, address and phone number of the employer If you have received any weekly benefit checks for your injury, what was the weekly amount?
YOUR INJURIES Please list all of the injuries you sustained in this accident List here any pre-existing or subsequent illnesses or accidents. This is particularly important, if they have any relation to the problems caused by your work accident. Failure to mention these matters, no matter how trivial they may seem, could be harmful to your case MEDICAL TREATMENT Were you transported to the hospital by ambulance? Yes No If yes, which ambulance company transported you?
Please list all hospitals, doctors, industrial clinics, physical therapy and/or diagnostic clinics where you have received treatment and/or testing for your injuries Who referred you to your physician (your employer, etc.)? List name of physician, treatment and date seen for your injuries Did your employer have a list of four or more doctors, clinics or hospitals posted in a prominent place? Yes No One-way mileage from home / office to doctor's office One-way mileage from home / office to pharmacy PRIOR INJURIES Prior to this accident, have you ever been injured in an automobile, slip and fall or work-related accident? Yes No If yes, please list the year, type of accident and part(s) of the body that were injured Prior to this accident, have you ever made a claim for personal injury, social security, disability insurance, unemployment benefits and/or workers' compensation? Yes No If yes, please explain List any past lawsuits you have been involved in, giving the full details as to each case Have you ever had surgery? Yes No If yes, list the dates and type of surgery you've had previously THE FOLLOWING INFORMATION WILL BE TREATED IN THE STRICTEST CONFIDENCE: If you have been treated for alcoholism or drug addiction; or convicted of a violation of any criminal statute (except minor traffic offenses), please list and discuss with your attorney only.Please list any questions you have regarding your Workers' Compensation Claim By clicking on "Finish Claim", I verify that the above information is accurate to the best of my knowledge.
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