WORKERS COMPENSATION CASE INTAKE FORM Client______________________________ Address_____________________________ ____________________________________ Phone: (H)____________(W)___________ Date Retainer Agreement Signed:_____________ Employer___________________________ Address_____________________________ ____________________________________ Insurer_____________________________ Adjuster_____________________________ Address____________________________ Claim No.___________________________ ___________________________________ Telephone___________________________ Managed Care Organization: Yes No Policy No._____________________ DATE OF INJURY:_____________________________ Date of Prior Workers Comp Claim_________________Amount of Award $___________ Date of Prior Workers Comp Claim_________________Amount of Award $___________ Date Workers Statement of Deposition Taken_________ Date of Determination Order/Notice of Closure_____________Statute Runs_____________ Date of Reconsideration Order___________________________Statute Runs_____________ Date of Denial Order___________________________________Statute Runs_____________ Aggravation Issues_____________________________________Statute Runs_____________ Date of Opinion and Order_______________________________Statute Runs_____________ Date of Board Order Mailing_____________________________Statute Runs_____________ Date Appellate Brief Due_______________________________ Date of scope of acceptance letter_________________________Statute Runs_____________ Date of Directors Admin. Review Order____________________Statute Runs_____________ Date of Medical Services Order___________________________Statute Runs_____________ Vocational Services Issue________________________________Statute Runs_____________ 1>>>> 2 WCD WCB Date Request for Hearing Filed______________ Date Request for Hearing Filed____________ Hearing Date____________________________ Hearing Date__________________________ Date Client Notified_______________________ Date Client Notified____________________ LIEN ITEMS Social Security Disability Child Support Liens Unemployment Benefits Welfare Assistance Private Health Carrier REQUESTS FOR RECORDS Records from treating physician Date Requested________________ Recd______________ Hospital Records Date Requested________________ Recd______________ Other physician records Date Requested________________ Recd______________ Other physician records Date Requested________________ Recd______________ Document demand to employer Date Requested________________ Recd______________ Medical releases obtained Date Requested________________ Recd______________ WITNESSES Interviewed Subpoenaed Name______________________________________________ Address________________________________________ _______________________________________________ Telephone_______________________________________ Name___________________________________________ Address_________________________________________ ________________________________________________ Telephone________________________________________ Name____________________________________________ Address__________________________________________ _________________________________________________ Telephone_________________________________________ 2>>>> 3Name_____________________________________________ Address___________________________________________ __________________________________________________ Telephone__________________________________________ Name_____________________________________________ Address___________________________________________ __________________________________________________ Telephone__________________________________________ 3