Forms
Auto Accident
Work Accident
Employer
Patient Information Form (Work Accident)
(1sWC) This is not a secure form - your responses will be e-mailed to us.
Section 1 - Your Information
Our file #(ournum)*:
Your Full Name*:
Your Email Address*:
Name of medical provider where you were treated for this accident:
Section 2 - Employer Information
Was your injury reported to your supervisor?
YES
NO
Name of your employer:
Employers mailing address:
Your employer's Worker's Compensation Insurance company name
(at the time of the accident):
Insurance Company Address:
Insurance Claim #
Section 3 - If an attorney is handling your case
Name of your Attorney:
Mailing address of your Attorney:
Telephone number of your Attorney:
