Workers Compensation Injury Comp Lawyers Attorneys Nassau Suffolk County Long Island Queens Brooklyn Bronx Manhattan New York

I PERSONAL INFORMATION (*Required Information)

*Your Name
Date of Birth

*Your Street Address

*City

*State

*Zip

*E-Mail

II ABOUT YOUR ACCIDENT OR INJURY

*List Any Other Injuries Or Conditions
*How did it happen?	* Where did it happen?

III ABOUT YOUR EMPLOYMENT

*Phone # (if known):
*Employer you worked for when you were injured. (Include name, and address)
Your Job (title, duties etc.)	Who at work was first notified of your injury
List witnesses (up to three,) who saw you get hurt. (If none leave blank.)
*Was an accident report completed? Yes No

IV INSURANCE COMPANY AND CLAIM NUMBERS (If you know.)

Name of Workers’ Compensation Insurance Company	Their Case Number
W.C.B.# (Case Number From N.Y.S. Workers’ Compensation Board)

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