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Partial Incapacity Benefits
If you have an earning capacity, but have not been cleared by your doctor to return to full duty, you may qualify for partial benefits for a maximum of 260 weeks. For certain types of severe incapacity, you may receive benefits for up to 520 weeks. Partial incapacity payments equal 60 percent of the difference between your average weekly wage prior to your injury and the weekly wages you are now capable of earning. The maximum compensation under this section of the law is limited to 75 percent of what your weekly total temporary benefits would be. For example, if you would receive $440 a week as a total temporary beneft, the most you could receive if you collected partial benefits would be $330 a week.

Filing a workers' compensation claim is a complicated and difficult task. If you would like your claim to be reviewed by an attorney, complete the form below for a free evaluation.

Free Partial Incapacity Benefits Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
City where accident occured:	*
State where accident occured:	*

Please briefly explain the incident that caused the injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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