Workers Comp intake

Potential clients (injured person) name*
Hidden
DOB*
DD slash MM slash YYYY
Inquirer Name (if different)
Inquirer’s relationship to injured person
Mailing Address*
Physical Address (if different)
City/State/Zip
Phone
Cell
Email Address*
Date of Injury
How did the work accident happen?
Body part(s) injured
Symptoms
Where (city, county) work injury happened?
Did you notify your Employer about the work accident? When exactly?
Were there witnesses to your work accident. Names, contact info.
Name / location of health care providers (HCP) who have seen you?
Chronology of your medical care, all the HCPs you have seen, starting with the first one
Did you go to the E.R. for your work injury? When, where?
Who chose the first HCP - you, or did someone tell you to go there?
Are you currently receiving monetary benefits from the WC insurer?
How much, how often?
Have you received any correspondence from the WC insurer (letters, phone calls, texts, emails)?
Have you been released to go back to work?
If so, is the Employer accommodating your physical work status?
Has the doctor released you, or told you that your medical care is complete?
Any pending medical care / treatment that the WC insurer is denying?
Spoken to other lawyers about your WC case?
Any recent or current proceedings in your case before the Workers Compensation Admin?
Is the WC insurance company offering you money to close out your case?
When you first started working for this Employer, was it in New Mexico or Texas?
Does the Employer take out for NM payroll taxes?
Do you have access to your payroll stubs dated in the time before the work accident?

(up to 6 mos. beforehand)
How have you felt physically since your work accident?
In terms of work, are you able to return to doing what you were doing before the work accident?
What are your daily activities of Daily Living

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Workers Compensation Intake

Workers Comp intake

Workers Comp intake

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El Paso Eastside Location:

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