Workers' Compensation

Notice
Making a false or fraudulent workers' compensation claim is a felony subject to up to 5 years in prision or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.*

* As required by California Law

Name:
Home Phone:
Work Phone:
Cell/Pager:
Email Address:
 
 

What was the date of the accident? (mm/dd/yyyy)

What is the name of your employer?

Do you still work for the employer?
Did you file a report with the employer?

If so, what was the date of the report?

Describe the accident and the nature and extent of your injuries.

Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.

Notice
Making a false or fraudulent workers' compensation claim is a felony subject to up to 5 years in prision or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.*

* As required by California Law