WORKERS’ COMPENSATION QUESTIONNAIRE

PERSONAL INFORMATION

Last Name _________________________ First Name___________________ MI _______ Address_______________________________________________________________________ City _______________________ State___________________ Zip Code__________ Telephone (Home) ___________________________ (Cell) ________________________ Other Phone or Pager____________________________ Fax:____________________________ Email_______________________________ Work or Other Phone __________________ Social Security No. ___________________________ Date of Birth __________________ Marital Status: S M D SEP W Name of Spouse __________________________________ EMERGENCY CONTACT: Relative or Friend who will always know how to reach you. Name: ________________________________________________________________________ Address: ______________________________________________________________________ Phone Number: ________________________________________________________________ How far did you go in school? _____________________________________________________ How did you hear about Attorney David K. May? _____________________________________

NOTE: PLEASE UPDATE OUR OFFICE WHENEVER YOU HAVE A CHANGE IN YOUR MAILING ADDRESS OR TELEPHONE NUMBER OR IF YOUR PHONE IS DISCONNECTED.

EMPLOYER INFORMATION:

Employer: _____________________________________________________________________ Address: ______________________________________________________________________ City: ______________________ State: ________________ Zip Code: _______________ Phone No.:_____________________________ Fax No.: ____________________________ Date Hired: _______________________ Job Title at time of injury: ____________________ Describe your job duties: _________________________________________________________

Name of your immediate supervisor: _______________________________________________ Job Title of immediate supervisor: _________________________________________________ Are you still employed with this employer? YES______ NO_______ If no, date terminated or resigned: _________________________________________________ Reason for termination or resignation: ______________________________________________

Are you a union member? YES______ NO_______ What is the nature of your employer’s business? ______________________________________ Is this your only employer? YES ______ NO _______ If no, please list the name and address of any other employer ____________________________

WAGE INFORMATION:

Hourly $ ________________________ Rate of pay (before tax deductions) Number of hours worked per day ________ Number of hours worked per week _______ Your wages are paid : Weekly

Monthly

Bi-Weekly

Other If you receive tips, bonuses, or commissions, how much did they average per week? __________

ACCIDENT INFORMATION:

Date of Accident: ______________________________ Time: ________________________ County of Accident: _____________________________________________________________ Location of accident (Where were you?) _____________________________________________

Is your employer denying you were hurt on the job? YES______ NO_______ Please describe in detail how the accident occurred (if you need more space, you may continue on the back):

Were you going to or from your job at the time of the accident, or on a work related errand? If yes, please describe:

Was a party other than your employer at fault in the accident? If yes then please describe:______________________________________________________________________

ATTORNEY INFORMATION:

Have you been represented by an attorney for this accident? YES ______ NO _______ If yes, please list his/her name, phone number and address: _____________________________

Have you terminated the attorney? YES______ NO_______ Please state why the attorney was terminated or has resigned_____________________________

If the attorney has been terminated or has resigned, has the attorney filed a lien? YES______ NO_______

YOUR INJURIES: Please list all of the injuries you sustained in this accident: ______________________________

WITNESSES:

1. Name: _____________________________________________________________________ Address: ______________________________________________________________________ City: ___________________ State: __________________ Zip Code: _________ Telephone (Home): __________________________ (Work): _______________________
2. Name: _____________________________________________________________________ Address: ______________________________________________________________________ City: ___________________ State: __________________ Zip Code: _________ Telephone (Home): __________________________ (Work): _______________________
3. Name: _____________________________________________________________________ Address: ______________________________________________________________________ City: ___________________ State: __________________ Zip Code: _________ Telephone (Home): __________________________ (Work): _______________________
4. Name: _____________________________________________________________________ Address: ______________________________________________________________________ City: ___________________ State: __________________ Zip Code: _________ Telephone (Home): __________________________ (Work): _______________________

NOTICE:

Did you give notice of the accident to your employer? YES______ NO_______ Name and Job Title of person to whom you gave notice: ________________________________ Give details of how you gave notice, including date, time, place, and witnesses:

WORKERS’ COMPENSATION INSURANCE INFORMATION:

Workers’ Compensation Insurance or Claims Management Company:

Address: ______________________________________________________________________ Adjuster Name:_______________________ Phone No.: _________________ EXT: _______ Fax No.: _________________________ Adjuster email address:__________________________ Claim Number: _________________________________________________________________ Have you spoken to the insurance adjuster? YES NO Have You Been Denied Any Weekly Checks or Medical Treatment? YES______ NO ______ If yes, please list all income benefits or medical treatment being denied by workers’

compensation and why the insurer is denying benefits

WORKERS’ COMPENSATION BENEFITS:

Have you received any weekly benefit checks for your injury? YES NO If yes, what was the weekly amount? _______________________________________________ Have you been disabled from work or been given work restrictions? YES NO If you have work restrictions in place, please list your restrictions: ________________________

When did you first lose time from your job due to your injury? ___________________________ Are you still off the job due to your injuries? YES NO If you returned to work for the same employer, when did you go back to work? ______________ Did you have any decrease in your earnings after returning to work? YES NO Have you at anytime lost income due to your injuries after the accident? YES ____ NO_____ Have you used any “sick days” offered by your company? YES ______ NO _______ Have you been assigned an impairment rating? YES ______ NO _______ If yes, please list the impairment rating you have been assigned and who assigned it.

If you are working or have worked for another employer since your accident, list the name, address, and phone number of the employer and the dates you worked: ____________________

MEDICAL TREATMENT:

List every provider where you have had medical treatment for injuries suffered in the accident Please Note: You should request your work status in writing after each visit with your primary doctor, and provide a copy to my office. All referrals from your doctor must be in writing for them to be approved by the insurance company. Please keep our office updated regarding your medical treatment and work status and provide our office with a copy of any records or bills you receive. In addition, should any offer of employment be made to you, please let me know immediately. Under no circumstances should you return to work without first discussing the matter with your attorney.

OTHER INSURANCE INFORMATION:

Health Insurance Company (including Medicaid/Medicare):_____________________________ Address: ______________________________________________________________________ Phone No.: ____________________ Fax No.: _______________________ Policy Number: __________________________ Insured: ___________________________ Has you health insurer paid any benefits from your work accident? YES______ NO_______ Has you health insurer denied any benefits from your work accident? YES______ NO_______ Do you have any additional insurance or other disability benefits compensating you or

potentially compensating you for wage loss or providing other benefits? YES_____ NO______ If yes, please describe the coverage or benefits and list the name and address of the insurer/benefit provider:

Do you have a private disability insurance plan with your company? YES______ NO ________

Has you private disability insurance plan paid any benefits from your work accident? YES______ NO_______ Has your private disability insurance plan denied any benefits from your work accident? YES______ NO_______

Do you have any additional insurance or other disability benefits compensating you or potentially compensating you for wage loss or providing other benefits? YES_____ NO______

Are you a veteran of the United States Armed Forces? YES______ NO _______ If yes, have you treated at the VA for injuries sustained from your work accident? YES_____ NO______

Do you reside in Fulton or Dekalb County? YES______ NO ______

If yes, have you treated in the Grady Health System for any reason? YES______ NO _______

PRIOR INJURIES:

Prior to this accident, have you ever been injured in a work-related accident or filed a workers’ compensation claim? YES NO

If yes, please list the type of accident and approximate date of injury:

Prior to this accident, have you ever been injured in any non-work related accident?

YES________ NO_________

Prior to this accident, have you ever filed a claim for personal injury, social security, disability insurance or unemployment benefits? YES_____ NO______

If yes, please list the type of claim filed, the company or state agency the claim was filed with, why the claim was filed, and the disposition of the claim:

Please list any medical conditions or diseases you have which are unrelated to your work accident:

Do any of the above referenced medical conditions or diseases interfere with your ability to work? YES_____ NO______

List any past lawsuits you have been involved in, giving the full details as to each case:

Were you represented by an attorney for any of the above-referenced accidents, claims or lawsuits? YES_____ NO______

If yes, please list the attorney’s name, address, phone number and the accident, claim or lawsuit for which you were represented:

Have you ever had surgery for this accident or any other accident? YES_____ NO______

THE FOLLOWING INFORMATION WILL BE TREATED IN THE STRICTEST CONFIDENCE:

Have you ever been diagnosed either by yourself or a health care provider as suffering from alcoholism or drug addiction? YES _______ NO_______

If yes, please describe ___________________________________________________________

Have ever been treated for alcoholism or drug addiction or sought assistance at a detox center? YES_________ NO __________

Please list when and where you have been treated for alcoholism or drug addiction

Have you ever been arrested or convicted of a violation of any criminal statute? (except minor traffic offenses). If yes, please list the date of arrest, the jurisdiction where arrested, disposition of the case, whether you were convicted of a misdemeanor or felony, and please discuss below with your attorney.

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I VERIFY THAT THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

Date Client Signature