Client Workers' Compensation Application
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Indicates a required field
Client Information
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First Name:
*
Last Name:
*
Social Security #:
*
Address:
Apartment/Suite:
*
City:
*
State:
*
Zipcode:
*
Home Phone:
Work Phone:
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Date of Birth:
E-Mail Address:
Occupation:
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Employer:
*
Amount Requested:
$500
$750
$1000
$1500
$2000
Other
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I have a Personal Injury Law Suit/Claim/Action:
Accident
Description
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Date of Incident:
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Claim Date:
*
Describe the Incident:
Physical Damages
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What damages did you suffer as a result of the accident?
*
Description of Future Treatment:
I have reached MMI (Maximum Medical Improvement):
Yes
No
Lost Wages
Dates you were unable to work:
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From:
*
To:
(mm/dd/yyyy)
Have you returned to work?:
Yes
No
Were you out of work continuously between these dates?
Yes
No
If not, explain:
Days lost from work:
Wages:
$
Per
Hour
Day
Week
Bi-weekly
Month
Year
Wages Other:
Disability
Extent of Disability:
Temporary
Permanent Partial
Permanent Total
None
Disability Rating:
Date of Rating:
What part of your body is disabled?
Have you applied for Social Security Disability:
Yes
No
Attorney Information
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Name:
*
Firm:
*
Address:
*
City:
State:
*
Zip:
*
Telephone:
Fax:
Paralegal:
12140 Lackland Road
St. Louis, Missouri 63146
Phone 314.446.3600
Fax 314.446.3601
St. Louis, Missouri 63146 Phone 314.446.3600 Fax 314.446.3601