Free Workers' Compensation Claim Evaluation

Have you been injured on the job? Do you need medical treatment? Are you disabled as a result of the work injury? You may be eligible for medical treatment and weekly disability payments. Please complete the following questionnaire and submit it for an evaluation of your claim. There is no charge for the evaluation.

* Items are required.
First Name:* Last Name:*
*E-mail Address:
Home Phone:
 - -
Cell Phone: - -
Work Phone: - - ext.
Street Address:
Address #2:
City:
State/Zip: /
What is the best way to reach you?
Please provide the best place, time and method for contacting you.
Employer's Name:
Employer's Address:
Job Title:
Number of Years Employed:
Date of Injury:
Did injury occur in Pennsylvania: Yes: No:
Did the injury occur on your employer's premises? Yes: No:
Please briefly explain the incident that caused your injury:
Please describe your injuries?
Do you believe that any of your injuries are permanent? Yes: No:
Do you have a permanent visible scar on your face, head or neck? Yes: No:
Are you a federal employee? Yes: No:
Has a claim been accepted? Yes: No:
If yes, has the insurance carrier filed a petition to modify, suspend or termination your claim? Yes: No:
If No, have you received a notice of denial? Yes: No:
When did you first receive medical treatment?
How did you hear about us?