Workers' Comp Intake
Name (*)
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Email address (*)
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Home Phone (*)
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Cell Phone
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Address (*)
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How did you hear about the Ramos Law Firm? (*)
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If attorney, friend or other, please provide name/detail
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What date did your injury occur on?
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Who were you working for? (*)
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What is their address?
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What date did you start working for this employer?
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Were you working for anyone else while you were working for this employer?
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If yes, who?
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Briefly, describe your job title and duties
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What were you earning?
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Did the employer take out taxes on your behalf?
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Briefly, how did the accident occur?
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What body part(s) did you hurt? Include all the places you had pain. (*)
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What doctors or medical facilities have you treated with?
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When was the last time you saw a doctor about your work injury?
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Which doctor was this treatment with?
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Do you have any prior injuries to the body parts hurt in this accident?
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Have you missed time from work?
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When did you start missing time?
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Were you terminated by the employer?
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Have you returned back to work?
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If no, why not?
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Have you ever been a party to a lawsuit?
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Have you ever been arrested?
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Do you have any other personal injury actions pending as a result of this accident?
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If yes, please describe and state your attorney's name.
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Have you ever filed a workers' compensation claim before?
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Please state when, who your employers were, and how it was closed
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Are you currently represented by an attorney for any purpose? (*)
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What is the name and address of that attorney?
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Enter the letters shown in the box below Enter the letters shown in the box below
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