Workers' compensation client intake form

A free intake form for workers' compensation firms. Part 1 is the form a new client fills in: post it on your website, send it as a PDF, or hand it over in the office. Part 2 is the questions your intake staff should ask next, because a form's answers often point to something the form can't ask about.

Print this page, or save it as a PDF from your browser's print dialog. Change it to fit your firm and your state.

This is a template, not legal advice. Notice and filing deadlines differ by state, and federal employees have their own system.

Part 1: The client form

About you

Full name: ____________________
Phone: ____________________ Email: ____________________
Best way and time to reach you: ____________________
Mailing address: ____________________
Date of birth: ____________________
Are you filling this in for someone else? ☐ No ☐ Yes. Your name and your relationship to them: ____________________

Your job

Employer's name: ____________________
Your job title, and what you do: ____________________
Date you started: ____________________
How you are paid: ☐ Paycheck from the employer ☐ As a contractor ☐ Through a staffing agency ☐ Through an app ☐ Not sure
Your usual pay, including overtime: ____________________
Do you have a second job? ☐ No ☐ Yes. Where: ____________________

What happened

Date of the injury, or, for an illness, the date you first linked it to your work: ____________________
Where it happened, including the state: ____________________
What were you doing when you were hurt? ____________________
In your own words, what happened: ____________________
Did a person or company other than your employer cause or add to the injury, such as another driver, a property owner, an equipment maker, or another company working on the site? ☐ No ☐ Yes ☐ Not sure. Who: ____________________
Did anyone see it happen? ☐ No ☐ Yes. Their names: ____________________

Reporting the injury

Did you tell your employer? ☐ No ☐ Yes. When, how, and whom you told: ____________________
Was an incident report made? ☐ No ☐ Yes ☐ Not sure
Has a workers' compensation claim been filed? ☐ No ☐ Yes ☐ Not sure. When: ____________________

Your injury and treatment

What was hurt? ____________________
What did a doctor tell you is wrong? ____________________
Who are your doctors? ____________________
Did you choose your doctor, or did your employer or the insurance company? ____________________
Are you still being treated? ☐ No ☐ Yes
Has the insurance company refused any treatment? ☐ No ☐ Yes. What: ____________________
Did you have an injury or condition in the same part of your body before this? ☐ No ☐ Yes. Please describe: ____________________

Work and benefits since the injury

Are you working now? ☐ No ☐ Yes, my usual job ☐ Yes, light duty ☐ Yes, a different job
Date you stopped working: ____________________ Date you went back, if you did: ____________________
Have you received weekly checks from the insurance company? ☐ No ☐ Yes ☐ They stopped. When: ____________________
Has your claim been denied? ☐ No ☐ Yes. Date of the letter: ____________________
Do you receive, or have you applied for, disability, Social Security disability, or unemployment? ☐ No ☐ Yes. Which: ____________________

Letters and papers

Have you received letters from an insurance company or a state workers' compensation agency? ☐ No ☐ Yes
Do you have a hearing date? ☐ No ☐ Yes. Date: ____________________
Have you been offered a settlement, or asked to sign anything? ☐ No ☐ Yes. What: ____________________
Have you given a statement to your employer or an insurance company? ☐ No ☐ Yes ☐ Not sure
Have you talked with another lawyer about this? ☐ No ☐ Yes

Anything else

Is there anything else we should know? ____________________
How did you hear about us? ____________________

Sending this form does not make this firm your lawyer. The firm will contact you to talk about whether it can help.

Part 2: The questions to ask next

A form takes the answer it gets. These are the questions to ask when an answer is thin, or when it points to something the form didn't ask. Each one starts from an answer on the form.

Deadlines

The client told the employer late, or hasn't told them. Get the date, the way they told, and whom they told. Some states require notice within days of the injury.
An illness came on over time. Get the date the client first linked it to work.
A denial letter, a hearing notice, or a decision arrived. Get its date, and ask the client to bring it.
The client was hurt in one state and hired in another. Record both states.

Who the employer is

The client is paid as a contractor, through a staffing agency, or through an app. Ask who set the hours, who supplied the tools, who paid them and how, and who directed the work that day. A staffing agency, a subcontractor, or a gig platform may be the employer.
The client works for the federal government. Record the agency. Federal employees have their own system.

Someone other than the employer

Another driver, a property owner, an equipment maker, or another contractor caused or added to the injury. Ask who, and who directed the work that day. The client may also have a personal injury claim against them.

The client's own part

The other side will look for something the client did. Ask about it plainly now, so the attorney hears it first:

What the client was doing at the moment of the injury.
Whether anyone told them to stop, or to keep going.
Whether safety equipment was provided, and whether they were using it.
Alcohol, drugs, or medication that day, only where your firm asks and the matter may turn on it.

Treatment and benefits

Treatment was refused. Ask what was refused, when, and by whom.
Weekly checks stopped. Ask when, and whether a letter said why.
The insurance company sent the client to a doctor. Get the doctor's name, and what the doctor said.
An earlier injury to the same body part. Ask when, how, and what treatment it had.
The client receives other benefits. Ask which ones, and since when. A Social Security disability claim may need its own attention.

Since the injury

The employer paid the client money directly. Ask how much, when, and what the employer called it.
The client signed something, or may have. Ask what, and ask for a copy.
The client was offered a settlement, or is being pressed to settle. Ask who made the offer, for how much, and by when they must answer.

Situations to handle with care

The client was fired, demoted, or threatened after reporting the injury. Get the dates. The client may also have an employment claim.
A worker died on the job. Learn who the survivors are.

When the matter may be another area of law

Hurt as a seaman or a harbor worker, or on a vessel: maritime law may apply.
A private disability insurance denial with no work injury: not a workers' compensation matter.

Ask these questions without a form

Verantel asks these questions as an interview. It talks with the people who reach your firm, in plain language and in their own language, and asks the next question when an answer points to a notice deadline, a denied benefit, or someone other than the employer who caused the injury. Then it hands your firm a structured record, with the interview line each fact came from. Verantel is not a lawyer and gives no legal advice.

Verantel is in private beta.