Work's Compensation Legal Clinic of Louisana

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Client
First Name:
Last Name:
Middle:
Address:

City:
State:	Zip
Home Phone:	(xxx) xxx-xxxx
Other #	(xxx) xxx-xxxx
Social Security #:	xxx-xx-xxxx
Date of Birth:	mm/dd/yyyy
Marital Status
Spouse Name:
Education:

YOUR EMPLOYER (At Time of Accident):

Street Address:

City:
State:	ZIP:
Telephone #:	(xxx) xxx-xxxx
Fax #:	(xxx) xxx-xxxx
Job Title:
Supervisor:
Nature of Employer's Business:

Date of Hire:	mm/dd/yyyy

WORKER'S COMP./INS CO:
Claim #:
Adjuster:
Telephone #:	(xxx) xxx-xxxx
Street Address:

City:
State:	ZIP:

ACCIDENT
Date of Accident:	mm/dd/yyyy
Describe in full how the accident occured, give full details:


Injuries:


Any Scarring or disfigurement:


Date Accident reported and to whom:

Witnesses:
1:
2:
3:
4:

Worked since your accident? Yes No
Where:
When:
How Much Earned:

Medical Evaluation & Treatment
Hospital/EMR:
Doctor 1:
Type:
Your Choice or Company?:

Doctor 2:
Type:
Your Choice or Company?:

Doctor 3:
Type:
Your Choice or Company?:

Positive On Drug Screen?: Yes No

Prior Injuries
Date:
Nature:
Claim Made:
Work Related? Yes No

Date:
Nature:
Claim Made:
Work Related? Yes No

WAGES:
Per Hour
Hours Per Week
and your Average Weekly Wage
AWW

Have you ever or are you currently receiving any compensation benefits as a resuly of this injury? Yes No
Weekly Compensation Amount:
Have they been cut off: Yes No
Have your bills been turned over to a collection agency: Yes No

Why are you seeking legal advice?

Louisiana Revised Statute 12:1208
MISREPRESENTATIONS CONCERNING BENEFIT PAYMENTS; PENALTY

A. If, for the purpose of obtaining or defeating any benefit or payment under the provisions of this Chapter, any person, either himself or any person, willfully makes a false statement or representation, he shall be fined not more than five hundred dollars or imprisoned for not more than twelve months.

B. In addition to the criminal penalties provided for in SubSection A of this Section, any person violating the provisions of this Section may be assessed civil penalties by the director of not less than one hundred, no more than five hundred dollars.

C. Any employee violating this Section, upon determination by a hearing office, may forfeit any right to compensation benefits under this Chapter.

Acts 1989, No. Sect 5, eff Jan. 1, 1990.

STATE OF LOUISIANA PARISH OF ORLEANS

AFFIDAVIT OF VERIFICATION

I hereby certify that all statements, written in this interview form, and any subsequent representations whether written or verbal to this law firm are true to the best of my knowledge.
I understand that certain penalties and/or criminal charges may be applicable for willful false statements or misrepresentations and certify that I hold harmless this law firm, and its attorneys for any such misrepresentations or statements on my part.
I will immediately notify this law firm should I return to any type of employment in order to discontinue any weekly worker's compensation benefits.

Entering your initials is your agreement to the above statements:

EMPLOYEE/CLIENT INITIAL:

DATE: