LeClair & LeClair, P.C. - Workers Compensation Form

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Workers Compensation Form

If you are interested in having LeClair & LeClair, P.C. handle your case, please feel free to fill out the following client information form. If you have sent us a client information form and have not heard from us within 24 hours, please make sure that you telephone us to insure we received your information. Prior to LeClair & LeClair, P.C. accepting any case and assuming responsibility for that case, you will have to have a consultation with one of our attorneys and a written fee agreement will have to be executed by you and LeClair & LeClair, P.C.. While not all injuries give rise to a cause of action, we are willing to provide you with a free, no commitment consultation to discuss your case. Whether or not LeClair & LeClair, P.C. agrees to handle your case, any information that is provided to us will be kept confidential and will not be given to any third party without your consent.

General Information
E-Mail Address:
Today's Date:
Name:
Address:
City:	State: Zip Code:

County:
Home Phone:
Work Phone:
Date of Birth:
Date of Injury:
Social Security Number:
How did you hear of LeClair & LeClair, P.C. Law Firm?
The Injury
Type of Injury
How were you Injured?
What are the names of the witness(es) to your injury?
Date you gave notice of your injury to your employer:
What are the names of witnesses who saw or heard you give notice of your injury to your employer:
Name of your treating physician
Please list the doctors and all medical providers you have seen for injuries from this fall:
Has your doctor returned you to work yet?	yes no
Has your doctor told you to change jobs?	yes no
Has your doctor given you work restrictions?	yes no
If yes, what are they?
Have you gone through a Funtional Capacity Assessment (FCA)?	yes no
If yes, when?
Where?
Have you been given an impairment rating?	yes no
If yes, what was the rating?
Amount of weekly check from w/c Insurance Co?
Has the W/C Insurance Co denied benefits in writing?	yes no
If yes, date?
Has the W/C Insurance Co paid all of your medical bills?	yes no
What is the amount of the medical bills that are not yet paid?
Has the W/C Insurance Co paid your time off work?	yes no
If no, If no, please give the dates you were off work.
How much of that time off work was paid by the WC ins. Co.?
By who / what insurance company?
Work Losses
Who was your Employer when you were injured?
What was your job description?
What were your job duties when you were injured?
What was your hourly pay rate?
Who is your Employer now?
What is your new job description?
What are your new job duties?
What is your new hourly pay rate?
What is your work experience?
What is your education level?
Other Injuries
Have you had any other similar injuries?	yes no
Have you had any subsequent injuries or claims	yes no
If yes to either of the previous 2 questions, describe the situation (include dates):
Insurance Information
Worker's Comp Insurance Company:
Company name:
Adjuster:
Address:
Phone number:
Insurance claim number:
Your Health Insurance Company:
Company name:
Adjuster:
Address:
Phone number:
Insurance policy number:
Insurance claim number:

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This web site is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. Persons accessing this site are encouraged to seek independent counsel for advice regarding their individual legal issues.

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