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Workers' Compensation Patient Form - English
Required fields are marked with an asterisk *.
What hospital did you go for treatment?
Employment Information: What is the name and address of the employer you were working for when the accident happened?
Date of injury or accident
Who should we contact at your place of business?
Do you know the name and address of the worker's compensation insurance carrier?
If you know it, please provide a claim number
If you know it, please provide the name of your claims adjuster
Name of Health Insurance Company
Name of individual whose whole name is on the policy
Have you hired an attorney to help you in this matter?
If yes, please give name, address and phone:
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