Workers' Compensation Information Center

Workers' Compensation Contact Form

Name

Email Address

Phone Number

When were you injured?

Were you working at the time of the accident?
Yes  No 

For whom?

What work-related activity were you engaged in at the time you were injured?

How did the accident happen?

Were your injuries caused by any tool/equipment failure?
Yes  No 

If your injuries were caused by a tool/equipment failure, who manufactured the equipment with which you were working?

When did you first seek medical care for your injury?

What was/is your diagnosis?

Prognosis?

Who is your physician(s)?

Had you ever experienced similar symptoms prior to the date of your accident?
Yes  No 

Did the accident exacerbate a pre-existing injury?
Yes  No 

Has your doctor authorized you to return to work?
Yes  No