Ocel Law Office

Ocel Law Office, P.A.

Peter M. Ocel, Esq.

14501 Granada Drive, Suite 200

Apple Valley, MN 55124

Phone: 952-431-6226 (x102)

Facsimile: 952-431-4090

WORKERS’ COMPENSATION INJURY QUESTIONNAIRE

STATEMENT OF CONFIDENTIALITY: This is a confidential questionnaire for the use of our office only in preparing your claim for personal injuries. The information you furnish us will not be released and will be held strictly confidential. Please answer every question to the best of your ability.

CLIENT OVERVIEW

Your Name:

Address:

City:State:Zip:

Telephone:(H)(W)

Who referred you to Ocel Law Office, P.A.?

PERSONAL DATA

Birthdate:

Birth Place:Sex: M/F

Social Security #:--

Marital Status:Spouse Name:

How Many Dependents:Highest Level of Education:

Dependents Names and Ages: ______

INSURANCE DATA

Your Health Insurance:

Address:

Telephone:()Policy Number:

EMPLOYMENT OVERVIEW

Employer:

Address:

Wage per week:$Job Title:

Number of hoursAverage number of overtime hours per

Worked per week:week prior to injury:

Date of Hire:Supervisor:

Briefly describe the nature of your work, indicating the type of physical activities it involves (such as how much bending, lifting, stooping, etc.):

WORKERS’ COMPENSATION INFORMATION

Work Comp Insurer:

Address:

Adjuster Name:

Telephone:()Policy Number:______

HOW WERE YOU INJURED

Date Injured: ( if repetitive trauma type injury – date symptoms started )

Where did your injury occur?

How did your injury occur?

Describe in your own words what injuries you received:

List days working but making less money as a result of restricted duties:

INJURY WITNESSES

Was this accident investigated by anyone? Yes No

If yes, who investigated, and what company were they from?

Did you sign any statement regarding this accident? Yes No

If yes, who took the statement(s)?

Do you have a copy that you can provide our office with? Yes No

List the information requested for any who witnessed your injury.

Name

/

Address

/

Relationship

PREVIOUS INJURIES

List the information requested for any other injuries/accidents that happened before your workers’ compensation injury. (Use the back of this sheet for additional space.)

Date / Injury Description / Off Work From: / To:

CURRENT BENEFITS

Are you currently being denied work comp benefits? Yes No

If yes, please check all that apply:

Medical/Chiropractic Care Permanent Injury Retraining

Wage Loss Mileage Reimbursement Rehabilitation

Have you received any other benefits since your work comp injury?

Unemployment Welfare

General Assistance AFDC

SSDI VA Benefits

Long-term Disability Short-Terms Disability

(Paid by: )(Paid by: )

Other:

AS A RESULT OF YOUR INJURY

List all doctors you have seen as a result of this accident. (Use the back of this page for additional space.)

Doctor:

Clinic Name:

Address:

City:State:Zip:

Phone:()Date 1st treated:

Round trip miles:

**************************

Doctor:

Clinic Name:

Address:

City:State:Zip:

Phone:()Date 1st treated:

Round trip miles:

**************************

Doctor:

Clinic Name:

Address:

City:State:Zip:

Phone:()Date 1st treated:

Round trip miles:

**************************

Doctor:

Clinic Name:

Address:

City:State:Zip:

Phone:()Date 1st treated:

Round trip miles:

MEDICAL HISTORY BEFORE ACCIDENT

List all doctors or chiropractors you have treated with before this accident. (Use the back of this page for additional space if necessary.)

Doctor:City:

What were you treated for?

Date of last treatment:

**************************

Doctor:City:

What were you treated for?

Date of last treatment:

**************************

Doctor:City:

What were you treated for?

Date of last treatment:

**************************

Doctor:City:

What were you treated for?

Date of last treatment:

PREVIOUS EMPLOYMENT

List your employers for the last 10 years, starting with the most current:

Employer:

Address:

Occupation:Wage per week:$

Reason for leaving:

Hire Date:Termination Date:

**************************

Employer:

Address:

Occupation:Wage per week:$

Reason for leaving:

Hire Date:Termination Date:

**************************

Employer:

Address:

Occupation:Wage per week:$

Reason for leaving:

Hire Date:Termination Date:

**************************

Employer:

Address:

Occupation:Wage per week:$

Reason for leaving:

Hire Date:Termination Date:

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