Workmans Compensation Claims and Settlements

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	Death Benefits Partial Incapacity Benefits Permanent and Total Incapacity Benefits Permanent Loss of Function and Disfigurement Temporary Total Incapacity Benefits


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How benefits are determined
Most benefits are based on your average weekly wage (AWW) prior to your injury (including overtime, tips, etc.), going back up to 52 weeks prior to your date of injury. If you have not been in your current job long enough to fairly determine your AWW, the insurer will use the actual wages of a co-worker who has been in a similar job as yours long enough to determine an AWW.

You are also entitled to adequate and reasonable medical care. You will also be paid mileage for travel to and from medical visits. For your first visit to the doctor or hospital your employer has the right to designate a health care provider within the employer’s preferred provider arrangement. After that initial treatment, you have the right to choose your own health care providers. You may change these providers one time without the permission of the insurer. To change providers again you will need the insurer to agree to the change. The insurer has the right to send you to see its doctor for evaluation of your incapacity.

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 Workers Comp 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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