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Registration for Work Injury Claims

Registration for Work Injury Claims

At Antonucci Law, our accident lawyers balance extensive legal experience, skill, and genuine compassion to help people just like you set things right.

Call (908) 747-4477 or submit the details below of how you were injured and to schedule a free, no-risk case assessment.

Work Accident

Was the person who caused the accident a co-worker?
Yes No

Was a police report or incident report prepared?
Yes No

Did your employer admit that the accident occurred?
Yes No

Names/Addresses/Job Title of any witnesses to the accident:

Are you a Medicare Recipient?
Yes No

Are you a Medicaid Recipient?
Yes No

Private Health Ins. Coverage?
Yes No

Did your health insurance carrier pay for any medical treatment related to the work accident?
Yes No
(if yes, fill the following details)

Workers' Compensation Insurance Carrier

Did you provide the workers' compensation carrier with a statement?
Yes No

Is this a seasonal job?
Yes No

Were you paid by
Weekly Bi-weekly Daily Other

Did you lose time from work because of the accident?
Yes No

Are you still out of work?
Yes No

Were you paid for your time out of work?
Yes No

Did you receive New York State Disability Benefits?
Yes No

Are you still receiving benefits?
Yes No

- VACATION TIME?
Yes No

- SICK TIME?
Yes No

Were you paid by the WC carrier for lost time?
Yes No

Is this rate at least 70% of your average gross weekly wages?
Yes No

Dates Paid by WC:

_

_

Periods Out of Work and Not Paid:

_

_

Did you apply for Social Security Disability?
Yes No (if yes, fill the following details)

Was your employment terminated after the accident?
Yes No (if yes, fill the following details)

Injuries Sustained

What parts of your body did you injure? Check all that apply

Head Neck Back Internal Pulmonary Dental Vision Left shoulder Right shoulder

Left Arm Right Arm Left Hand Right Hand Left Leg Right Leg Left Foot Right Foot

Do you have any current emotional/psychiatric complaints related to the accident or your injuries?
Yes No

Medical Treatment

Was an ambulance called to the scene?
Yes No
(if yes, fill the following details)

List the names and addresses of all hospitals, physicians, and medical facilities from whom you received medical treatment:
(no need to provide addresses of hospitals)

Treatment Received

MRIs:
Yes No Proposed

EMGs:
Yes No Proposed

Surgery:
Yes No Proposed

Physical Therapy

Injections:
Yes No Proposed

Prior or Subsequent Injuries

Did you ever injure the same body parts before or after the work accident?
Yes No

Dates of Prior/Subsequent Accidents:

General Description of Treatment Received:

Prior MRI?
Yes No

Prior Injections?
Yes No

Prior Surgery?
Yes No

Names and addresses of prior/subsequent physicians:

Yes No

Yes No

Yes No

Prior Lawsuits or Workers' Compensation Awards:

I understand that the answers I provide will be used to prepare my case, and if I am not completely honest, it will negatively affect the results of my case.

Call today for a free consultation (908) 747-4477 FREE CONSULTATION

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"A significant part of my success as a trial attorney, comes from the recognition that empathy and compassion are equally as important as my knowledge of the law and experience in the courtroom." - Stacey Antonucci

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