1Personal Information

2Referral & Accident Location

3Employer & Work Comp Insurance

4Treatment & Personal

5Employment & Pay

6Accident Details

7Medical & History

8Claim Status & Emergency Contact

9Documents & Signature

Personal Information

Name(Required)

First Last

DOB

Address

Street Address City State ZIP Code

Cell

Home

Do you send & receive text messages?

Yes

Email Address(Required)

Driver License

Social Security

Referral & Accident Location

How were you referred to our office?

Professional Referral

Client Referral

Name of Referral

Source

Walk-in

Unknown

Internet

Billboard

Fox 11

News 4

Channel 2

Location of Accident (City and State)

Was the accident reported to the employer?

Yes

Employer & Work Comp Insurance

Employer Name

Employer Address

Street Address City State ZIP Code

Employer Phone Number

Start Date

Work Comp. Insurance Company Name

Claim

Adjuster Name

Adjuster Phone

Adjuster Fax

Treatment & Personal

Are you treating with a doctor?

Yes

Are you currently out of work by a treating physician?

Yes

What is the name of the doctor you are currently treating with?

Marital Status

Married

Single

Divorced

Widowed

Do you have any children?

Yes

Do you owe any child support arrearages?

Yes

Is there a court order?

Yes

What is your highest level of education?

High School

GED

Grad School

Vocational Training

Training in what?

Degree

2 Year Degree

4 Year Degree

What type of degree did you receive?

Employment & Pay

Job Title

Start date of employment

Rate of Pay $

Per

Hour

Week

Monthly

Year

How per week

What are the dates lost from work because of injury?

Are you currently receiving checks from your employer?

Yes

Are you currently receiving Worker's Compensation checks?

Yes

Have you returned to work?

Yes

Have you been terminated?

Yes

Accident Details

Date of Accident

Time of Accident

Hours

Minutes

AM/PM

a.m./p.m.

a.m.

p.m.

Were there witnesses to the accident?

Yes

Describe how the accident happened

What are the injuries you received from the accident?

Medical & History

Did you have anything to drink on the day of the accident up to and including 12 hours prior?

Yes

Were any meds or drugs taken up to and including 12 hours prior legal or illegal?

Yes

Were you taken to the hospital?

Yes

By ambulance?

Yes

Have you been referred to any other doctor for treatment?

Yes

Do you have any prior complaints of any injured body parts (injuries or medical conditions)?

Yes

If so, what are they? (prior complaints)

Do you have any prior Worker's Compensation Claims?

Yes

If so, please explain (prior Worker's Comp Claims)

Did you have an attorney for the prior claim?

Yes

If so, who?

Do you have a criminal background?

Yes

If so, were you convicted?

Yes

What are the charges?

Do you have any other outstanding medical issues?

Yes

If so, please explain (outstanding medical issues)

Claim Status & Emergency Contact

Has your claim been accepted or denied by the insurance company?

Accepted

Denied

Date of the Letter

Emergency Contact

Relationship

Emergency Contact Address

Street Address City State ZIP Code

Emergency Contact Phone #

IMPORTANT DOCUMENTS NEEDED FOR YOUR CONSULTATION:

If you have any documents, pictures, reports or anything else you believe is important to your case, we will make copies at this appointment and your originals will be returned before you leave today.

Signature (type your full legal name)(Required)

Date

Consent

I agree to receive text messages from Herb Santos, Jr Law Firm at the number provided about my inquiry, including consultation scheduling, appointment reminders, document requests, and case status updates. Messages may be sent using automated technology.

Consent

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Consent

I'd like to receive emails from Herb Santos, Jr Law Firm with legal updates, helpful resources, and firm news. I can unsubscribe at any time using the link in any email.

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I understand that submitting this form does not create an attorney-client relationship.(Required)

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FREE CONSULTATION

Workers Compensation Intake Form

Personal Information

Referral & Accident Location

Employer & Work Comp Insurance

Treatment & Personal

Employment & Pay

Accident Details

Medical & History

Claim Status & Emergency Contact

IMPORTANT DOCUMENTS NEEDED FOR YOUR CONSULTATION: