Name *(Required) E-mail *(Required) Phone Number *(Required) Queries JOB INJURY INFORMATION Complete this part only for Job Injury Information. Date (mm/dd/yyyy) Time Location Description of Accident Workman's Compensation Case Number Claim Number Insurance Company Insurance Company Address Insurance Company Case Number Insurance Company Phone Number Employer's Name Employer's Address Hospitalized? Name of Hospital X-rays taken Attorney Name Attorney Address Are you working now? Time lost from work: From to (dates) ACCIDENT INFORMATION Complete this part only for Accident Information. Date (mm/dd/yyyy) Time Location How did accident occur? Auto Collision Other If an auto collision, please describe the circumstances If auto accident, were you Driver Passenger Pedestrian If auto accident, were you struck from Behind Right Side Left Side Front Auto was Parked Did your car strike the other(s) involved? Or did the other car strike yours? Yes No Undetermined As a result of the accident, were traffic citations issued to you? To the driver to the other car? To the driver of your car? List the extent of the injuries as you know them Did you require post-aqccident hospitalization? Check symptoms you have noticed since accident: Headache Neck Pain Neck Stiff Sleeping Problems Back Pain Nervousness Tension Irritability Chest Pain Dizziness Head Seems Too Heavy Pins and Needles in Arms Pins and Needles in Legs Numbness in Fingers Numbness in Toes Shortness of Breath Fatigue Depression Light Bother Eyes Loss of Memory Ears Ring Face Flushed Buzzing in Ears Loss of Balance Fainting Loss of Smell Loss of Taste Diarrhea Feet Cold Hands Cold Stomach Upset Constipation Cold Sweats Fever Symptoms other than above Have you lost any days of work? Dates: Insurance Companies involved: My Company Company of person responsible for injuries? Have you been contacted by an insurance adjuster or company representative regarding this claim? Do you have an attorney that has advised you in this case? Attorney Name Address Telephone Assignment If you wish to receive directly the First Party Automobile Benefits for services rendered to the above patient, please have the patient complete the following assignment. I hereby authorize payment directly to the above named Medical Provider of the automobile No-Fault Benefits otherwise payable to me, but not to exceed the balance due of the Medical Provider's permissible charges under Article 51 of the insurance law for services rendered. Enter Code Verification Code
Complete this part only for Job Injury Information.
Complete this part only for Accident Information.
