Workers' Compensation Information Center

Workers' Compensation Contact Form

Name

Email Address

Phone Number

When were you injured?

Were you working at the time of the accident or harmful circumstance? For whom?
Yes  No 

What work-related activity were you engaged in at the time you were injured?

How did the accident or harmful circumstance happen

Were your injuries caused by tool or equipment failure or use?
Yes  No 

If your injuries were caused by tool or equipment failure or use, who manufactured, distributed, and/or sold the equipment with which you were working?

When did you first seek medical care for your injury?

What was your diagnosis? Prognosis?

Who is your physician(s)?

Had you ever experienced similar symptoms in the past?
Yes  No 

Did the accident or harmful circumstance exacerbate a preexisting injury?
Yes  No 

Did the injury cause you to miss work?
Yes  No 

Has your doctor authorized you to return to work?
Yes  No 

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