When Bad Things Happen to Good People.

 

            PERSONAL INFORMATION

---

Your Name
Address
City
State	ZIP
Home Phone
Work Phone
Fax (if available)
E-mail
Best Times To Contact You

---

CASE DETAILS

Is this an Oregon Worker's Compensation claim, if so proceed.

If not, contact an attorney that handles claims in that state.

Do you have a denial?	Yes No
If yes, what is the date?
Has your doctor taken you off work as a result of your injury?	Yes No
If yes, how long have you been off?
Were you hospitalized?	Yes No
If yes, how long?
What is the name of the treating doctor(s)?
Body part(s) injured:	Back or Neck Injury Wrist Injury Elbow Injury Head Injury Hip Injury Knee Injury Shoulder Injury Stress/"Accepted Only" Death Significant Blood Loss Tissue Disruption Other
Nature of injury/condition

  

We will review your report and contact you as soon as possible.

Thank you !