Injured in a work accident?

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Please complete all required fields below.

• Have you notified your employer of the injury? No Yes
• Has your employer filed a claim with the insurance company? No Yes
• Have you received medical treatment for your injury? No Yes
• Do you have unpaid medical bills as a result of your injury? No Yes
• Has your employer’s insurance company rejected your claim? No Yes
• Are you unable to work as a result of the accident? No Yes
• Name *
• Phone *
• Email *