New York Workers' Compensation Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

Business Phone

Cellular or Pager

What date and time were you injured, or when did you discover a work-related illness?

For whom were you working?

Describe the work-related activity in which you were engaged at the time of your injury or exposure causing illness.

How did the injury occur?

Were your injuries caused by any tool/equipment failure?
Yes No

If your injuries were caused by a tool/equipment failure, who sold, distributed and/or manufactured the equipment?

What date and time did you first seek medical care for your injury or sickness?

What was/is your diagnosis and prognosis, including a description of your symptoms and recommended treatment?

Who is your physician?

Had you experienced similar symptoms prior to the date of your accident?
Yes No
If so, when?

Did the accident exacerbate a pre-existing injury or condition?
Yes No

Has your doctor authorized you to return to work?
Yes No

Copyright © 2011 FindLaw, a Thomson Reuters business

DISCLAIMER: This site and any information contained herein are intended for informational purposes only and should not be construed as legal advice. Seek competent legal counsel for advice on any legal matter.