Complete our Intake Form online and submit to our office or download a copy of our intake form here.
CLAIMANT
 
Name   Spouse

 
 
 
Address   City   State   Zip

 
 
 
Home #   Cell #   Work #   SSN #

v
 
 
 
Date of Birth   Age   Sex   Email Address

Referred by


EMPLOYER INFORMATION
 
Employer   Address

 
 
Phone #   Supervisor   Job Description

v
 
 
 
Date of Hire   Salary   Pension Plan   Still w/ Employer


CARRIER INFORMATION
Name

Address

 
 
Phone #   Adjuster   Adjuster Phone #


WORK STATUS




WORK HISTORY
Concurrent Employment

 
Address   Phone #

Education

Work History


INJURY (NON 112.18)
Type of Injury

 
 
+
-
D/A   Reported to   Time

 
v
 
NOI Filed   Date NOI Filed   Claim Accepted

City/County of Accident

Description of Accident


HEART/LUNG CLAIMS (FS 112.18)
Type of Injury

 
 
+
-
D/A   Reported to   Time

 
v
 
NOI Filed   Date NOI Filed   Claim Accepted

City/County of Accident

Description of Accident

Family History of Hypertension/Heart Disease

 
 
 
Tobacco User   How Long   Packs per Day   How Long Have You Quit

 
 
 
Diabetic   Height   Weight   Alcohol Use

 
 
Testosterone Use   How Long   When Did You Quit


HEART/LUNG PART II

Pre-Employment Physical (PEP)

Did you have a PEP when you started employment with your current employer  

Were there any cardiac abnormalities revealed at the time of your pre-employment physical (ie: evidence of either hypertension or heart disease)  

If yes, please describe

Have you been diagnosed with either hypertension or any type of heart disease  

 
If yes, what conditions have you been diagnosed with   Date Diagnosed


MEDICAL PROVIDERS

DOCTOR / FACILITY   WC Authorized?   PHONE

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


MEDICATIONS

 
 
 
 


MISCELANEOUS INFORMATION
Previous Litigation

Previous Attorney

Dependent Children  

Child Support Obligation


 
 
 
 
City   County   State   Amount Owed ($)   Amount Arrearages ($)



Captcha image
Show another codeShow another code
SUBMIT INTAKE FORM

Call Toll Free (866) 245-8977

         
ORLANDO: 541 S. Orlando Ave., Suite 310, Maitland, FL 32751
TAMPA: 13031 W. Linebaugh Ave., Suite 102, Tampa, FL 33626
MIAMI: 1108 Ponce De Leon Blvd., Coral Gables, FL 33134
JACKSONVILLE: 4811 Beach Blvd, Suite 204, Jacksonville, FL 32207
PALM BEACH: 420 US Highway 1, Suite 15, North Palm Beach, FL 33408