Please briefly describe your accident/how your injury came to be:
Your answer
Was someone else at fault? (If yes, please explain)
Your answer
Current employment status:
Clear selection
If still employed and still working, are you working under...
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Date of first doctor's visit: (leave blank if no visit yet)
MM
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DD
/
YYYY
Date of most recent doctor's visit:
MM
/
DD
/
YYYY
Did/do you have a 2nd job?
Clear selection
Did your employer provide you with medical/dental insurance for you and/or your family that was stopped? (please note: this is NOT your Workers' Compensation Insurance)
Clear selection
If you know your employer's workers' compensation insurance please include it here, if not then please leave blank.