Workers Compensation

Work related injury claims may by an employee against the employer.
Consultation Fee:
$0
 Fees:
Contingency
 Panels:
20%

Good _______ and thank you, for calling ASN, My name is ___________, how can I help you?

Do not forget to ask the following:

  • Have you used our service before? No Yes
  • How did you hear about our service?
  • Where are you located?
  • Where is your legal matter taking place?
Who needs legal help? Caller Other
Employer's type of business:
Length of time employed at employer's business
Type of work performed for this employer:
Date of the incident giving rise to the claim:
Location where incident occurred:
Did the incident occur during the course and scope of employment? No Yes
If yes, describe how incident occurred:
Were any injuries sustained as a result of the incident? No Yes
If yes, which part of the body was injured?
Was any medical treatment sought for the inury or injuries? No Yes
Has a claim been filed with the Workers Compensation Appeals Board? No Yes
Has a report of the incident and injury been made to the employer? No Yes
If yes, when was report made to the employer?
Has the incident caused time lost from work? No Yes
If yes, is temporary disability being paid during the time off work? No Yes
Are there any pending hearings in this matter? No Yes
Please state any other facts that may be helpful with this matter:

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