Fill and Sign the Workers Compensation Questionnaire 497426849 Form

WORKERS’ COMPENSATION CLAIM QUESTIONNAIRE I. PERSONAL INFORMATION       NAME (First, Middle, Last) NAME CALLED       MAILING ADDRESS - STREET ADDRESS (If Different from mailing address)       CITY STATE ZIP HOME PHONE       WORK PHONE       OTHER PHONE       AGE       DATE OF BIRTH       SOCIAL SECURITY NO.       MARITAL STATUS: Married/Single/Divorced/Widowed/Separated       Date of Marriage/Divorce/Widowed:       SPOUSE’S NAME       CHILDREN’S NAMES & AGES       SPOUSE GROUP INS.       OTHER HEALTH INS. COVERAGE       CRIMINAL RECORD       REGISTERED TO VOTE?       II. EMPLOYMENT INFORMATION:       EMPLOYER NAME       EMPLOYER PHONE NUMBER       EMPLOYER’S ADDRESS (Street, City, State, Zip) SUPERVISOR       DATE EMPLOYED       JOB TITLE       RATE OF PAY       AVG. HRS./DAY       SHIFT       SICK PAY       TEMPORARY TOTAL PAID? Y/N DATES       AMOUNT $       PART-TIME EMPLOYMENT? Y/N EMPLOYER             ADDRESS OF PART-TIME EMPLOYER RATE OF PAY       LOST WAGES? Y/N DATES MISSED       III. INSURANCE CARRIER INFORMATION:       WORKERS’ COMP INSURANCE CARRIER       CARRIER’S ADDRESS (Street or P.O.>Box, City, State, Zip)       ADJUSTER NAME &PHONE NUMBER       INSURED CLAIM NUMBER POLICY NUMBER IV. THIRD PARTY DEFENDANT:       ADVERSE PARTY’S NAME (First, Middle, Last) (Name of any person who caused injury)       AP’S ADDRESS (Street or P.O. Box, City, State, Zip) V. THIRD PARTY INSURANCE INFORMATION:       INSURANCE COMPANY       INSURANCE COMPANY ADDRESS       ADJUSTER’S NAME & PHONE NUMBER       INSURED VI. ACCIDENT INFORMATION: DATE OF INJURY       TIME       LOCATION       PART(S) OF BODY INJURED       DESCRIBE HOW ACCIDENT OCCUURED                                     ACCIDENT REPORTED? Y/N REPORTED TO       TITLE/POSITION       DATE REPORTED       WITNESSES (NAMES AND PHONE NUMBERS)                   VII. MEDICAL TREATMENT:       NAME & ADDRESS OF TREATER       NAME & ADDRESS OF TREATER       NAME & ADDRESS OF TREATER       NAME & ADDRESS OF TREATER VIII. CLAIM HISTORY:                         IX. PRIOR MEDICAL / CLAIM HISTORY: