Fill and Sign the Workers Compensation Worksheet Form

WORKER’S COMPENSATION WORKSHEET Client ______________________________ Case No. ______________________Address_____________________________Phone (H) _____________________City/State/Zip ________________________ Phone (W)_____________________Employer _________________________________________________________ Insurer____________________________________________________________Adjuster’s Name ______________________ Phone _______________________Adjuster’s Address__________________________________________________Attorney’s Name ______________________ Phone ______________________Address___________________________________________________________ _______________________ Bar No. _________ Fax _______________ 1. __________ Last Date to File Petition to Controvert ____________________2. __________ Initial Office Visit 3. __________ Employment Contract4. __________ Medical Release5.__________ Employment Records Release6. __________ Thank you letter allowing us to represent 7. __________ Mail contract and medical records to commission8. __________ Contact Adjuster9. __________ Request medical records10. ________ Medical records returned11. ________ Date of MMI ______________________12. ________ Attempt Settlement13. ________ File Petition to Controvert14. ________ File Discovery15. ________ Answers to discovery received16. ________ Answer discovery if filed, Date Due ____________________17. ________ Request doctor’s report18._________ Doctor’s report returned 19. ________ Notice doctor’s deposition(s)20. ________ Deposition date _________________________21. ________ Discovery Deadline ______________________22. ________ Prepare Pretrial Statement 23. ________ Court date or docket call date24. ________ Letter to client advising of date25. ________ Motions filed 26. ________ Motion hearing date _____________________27. ________ Letter setting pretrialTelephone Calls and Other MattersDate Spoke to: About:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date Spoke to: About:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________ __________________________________________________________________________