I am Seeking Help with a Worker's Compensation Claim
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Your Full Name
Your Phone Number
Your Email Address
Your Zip Code
About the Accident...
Did the Injury Occur at Your Workplace or While You Were Working?
Yes - at workplace
Yes - while working (ex. making a delivery)
No - not at work or while working
Date of Accident (Exact or Approximate)
Select an Injury Category
Primary Injury Type Sustained
Back + Neck Pain
Broken or Fractured Bones
Cuts or Bruises
Trauma to Vision
Headaches or other Body Aches
Trauma to Hearing
Dismemberment (loss of limb)
Other - described in detail below
Describe Your Incident in as Much Detail as You Can Please
What Action Have You Taken so Far?
No Action Taken Yet
Worker's Comp Claim Filed
Went To Doctor
Lawsuit Filed Against Workplace