WC and PI Questionnaire

Workman's Compensation (WC) and Personal Injury (PI) Questionnaire

Please complete this form to the best of your ability!

Name*

First NameLast Name

Today's Date*

Date

Cell Phone*

Home Phone

Work Phone

Subscriber Name

Subscriber SSN

Which type of case are you seeking treatment for?*

Workman's Compensation (WC)Personal Injury (PI)

Please complete the following questions if you are seeking treatment for a work-related injury, i.e. Workman's Compensation (WC)

Have you filed a WC claim or accident report with your employer?

YesNo

If yes to the question above, when did you file?

Your Employer

Claim Number

Adjuster's Name

Adjuster's Phone #

(000) 000-0000

Adjuster's email

example@example.com

Please complete this section if you are seeking treatment for an injury that another party or individual is responsible for, i.e. Personal Injury (PI). This includes homeowner's insurance, school insurance, personal liability, etc.

Policy Holder (Responsible Party)

Insurance Company (Responsible Party)

Insurance Company Phone (Responsible Party)

What was the date injury/accident occurred?

Date

Where did the accident occur?

Please give a description of the accident

Please give a brief description of your injuries incurred in the accident

Have you initiated any legal actions pertaining to the accident?*

YesNo

Attorney's Name

Attorney's Phone #

Attorney's Fax #

Attorney's Address