Workers’ Compensation Intake Forms: What Every Law Firm Needs to Capture on Day One

Workers’ Comp Is Not Personal Injury—Your Intake Form Shouldn’t Pretend Otherwise

We see it constantly: firms handling workers’ compensation claims using the same intake sheet they pull out for a slip-and-fall or a car wreck. On the surface it seems reasonable—there’s an injury, there’s a claimant, there’s medical treatment. But the legal framework is fundamentally different, and the intake form needs to reflect that from the first page.

Workers’ comp is a no-fault, administrative system. You are not filing a lawsuit in civil court. You are navigating a state-run benefits system with its own judges, its own procedural rules, and its own deadlines that bear no resemblance to a standard statute of limitations. The employer’s insurance carrier—not the employer personally—is the opposing party. And the remedies are statutory: medical treatment, temporary disability, permanent disability, vocational rehabilitation. There are no pain-and-suffering damages. There’s no jury.

A personal injury intake form is built for a tort claim. It captures negligence theories, liability percentages, property damage, and loss-of-consortium details. None of that applies here. What you need instead is a form purpose-built for the workers’ comp system—one that captures the employer relationship, the claim filing status, the injury mechanism in the language the Workers’ Compensation Board expects, and the administrative history that tells you where this case actually stands.

Employer Information: More Than Just a Name and Address

Every workers’ comp intake form captures the employer’s name. That’s table stakes. What separates a useful intake from a useless one is everything else about the employment relationship.

Employment Details That Matter

You need the claimant’s job title, department, and direct supervisor’s name. You need their hire date and, if they’ve been terminated or are on leave, the date and stated reason. You need to know whether they’re full-time, part-time, seasonal, or a temp-agency placement—because temp workers create dual-employer scenarios that affect which carrier is on the hook. Document the average weekly wage, including overtime, bonuses, and any second job with the same employer. Wage replacement benefits (typically two-thirds of the average weekly wage, capped by state maximums) are calculated from this number, so getting it wrong at intake means getting it wrong on the claim.

Capture the employer’s insurance carrier if the claimant knows it. In most states this information is posted in the workplace, and many claimants can pull it from their First Report of Injury. If the employer is self-insured, note that—it changes who you’re negotiating with and how.

The Retaliation Question

Ask it explicitly at intake: has the employer taken any adverse action since the injury was reported? Demotion, hours cut, termination, hostile reassignment, pressure not to file a claim? Retaliation claims under workers’ comp statutes are separate causes of action in most states, and they’re time-sensitive. If you don’t ask at intake, you may not learn about it until the window has closed. Your form should have a dedicated section—not a checkbox buried in a general notes field—for documenting these facts.

The Injury: Mechanism, Date, and the Reporting Chain

This is the core of the intake, and it’s where generic forms fail hardest. A personal injury form asks “describe the accident.” A workers’ comp form needs to be far more granular.

Mechanism and Classification

Start with the injury type classification. Is this a single traumatic incident (a fall from scaffolding, a machine crush injury) or a repetitive-stress / occupational disease claim (carpal tunnel from assembly work, hearing loss from factory noise, mesothelioma from asbestos exposure)? This distinction drives everything downstream: the applicable statute of limitations, the medical evidence needed, and the defenses the carrier will raise.

For traumatic injuries, capture the exact date, time, and location within the workplace. What was the claimant doing at the moment of injury? Who witnessed it? Was the area covered by security cameras? For occupational disease claims, capture the date the claimant first noticed symptoms, the date of diagnosis, and the date they first connected the condition to their work—because the filing clock often starts on that last date, not the first.

The Reporting Chain

Document when and how the injury was reported to the employer. Did the claimant fill out an incident report? Tell a supervisor verbally? Send an email? Most states require notice to the employer within 30 to 90 days of the injury (or discovery of occupational disease), and failure to report can be a complete defense. Your intake form needs to pin this down precisely: the date of the report, the method, and the person who received it. If the employer claims they were never notified, you need your client’s version documented from day one.

Prior Claims and Pre-Existing Conditions

The carrier will look for prior workers’ comp claims, prior injuries to the same body part, and any pre-existing condition they can use to argue the current injury is unrelated or a mere aggravation. Get ahead of this at intake. Ask about prior claims (with any employer, not just the current one), prior surgeries, and any ongoing treatment for the same body region. The goal isn’t to screen clients out—aggravation of a pre-existing condition is absolutely compensable in most states—but to know the full picture before the carrier springs it on you at a hearing.

Claim Status and Filing Deadlines

Many claimants walk into your office without having filed a formal claim. Others have filed but have been denied and don’t know what to do next. Your intake form needs to sort this out immediately.

Capture whether a First Report of Injury (FROI) has been filed. Has the claimant received a claim number from the state board or the insurance carrier? Has the claim been accepted, denied, or is it still pending? If denied, get the denial letter—it tells you the carrier’s stated basis, which dictates your strategy. If no claim has been filed, you’re on the clock. Most states impose a one-to-two-year statute of limitations for filing a workers’ comp claim from the date of injury (or date of last payment of benefits, depending on the state), but some are shorter—Iowa gives 90 days for the notice and two years for the petition. Missing this deadline is malpractice-level territory, so your intake form should capture the date of injury and flag the applicable filing window prominently, not bury it in a notes section.

If the claim is active, ask what benefits are currently being paid. Is the claimant receiving temporary total disability (TTD)? Temporary partial disability (TPD)? Have benefits been suspended or terminated? Has a settlement offer been made? Each of these scenarios requires a different immediate action, and you can’t triage without knowing the current posture.

Medical Treatment and the IME Problem

Workers’ comp medical treatment is not like treatment in a personal injury case. The claimant doesn’t just go to their own doctor and send the bills to the defendant’s insurer. In most states, the employer or its carrier has some degree of control over the treating physician—ranging from full control (the employer picks the doctor) to limited control (the claimant picks from a panel). Your intake form needs to document which treating physicians the claimant has seen, who selected them, and whether the claimant has been able to choose their own provider.

Independent Medical Examinations

Has the claimant been sent to an Independent Medical Examination (IME)? If so, by whom, and what was the result? IMEs are a standard carrier tactic—the “independent” physician almost always finds the claimant less injured than their treating doctor does, and the IME report becomes the basis for a denial or benefit reduction. If an IME has already occurred, you need that report. If one hasn’t been scheduled yet, document the treating physician’s current restrictions and prognosis so you have a baseline before the carrier’s doctor weighs in.

Maximum Medical Improvement and Disability Ratings

Has the treating physician declared the claimant at Maximum Medical Improvement (MMI)? Has a permanent impairment rating been assigned? These determinations trigger the transition from temporary to permanent disability benefits and are often the flashpoint for disputes. If the client has already reached MMI, the case is in a fundamentally different posture than if they’re still treating, and your intake form should capture this clearly.

Third-Party Claims and Return-to-Work Issues

Third-Party Liability

Here’s where workers’ comp intersects with personal injury. If someone other than the employer or a co-worker caused the injury—a negligent subcontractor on a construction site, a manufacturer of defective equipment, a reckless driver who hit the claimant while they were making deliveries—there may be a third-party tort claim in addition to the workers’ comp claim. This is where the real money is, because the third-party claim allows pain-and-suffering damages that comp doesn’t.

Your intake form must specifically ask whether any third party was involved. A generic form won’t prompt this question. The claimant may not volunteer it because they don’t know it matters. If you don’t capture the facts at intake, you may not identify the third-party claim until it’s too late—or until the workers’ comp carrier asserts its subrogation lien on a settlement you didn’t see coming. For more on capturing these overlapping liability scenarios, see our guide to personal injury intake form essentials.

Return to Work and Light Duty

Has the employer offered light-duty or modified work? Did the claimant accept or refuse? This is a minefield. In many states, an unjustified refusal of a bona fide light-duty offer can result in suspension of wage-loss benefits. But “bona fide” is doing a lot of work in that sentence—the offer has to be within the physician’s restrictions, it has to be a real job and not a manufactured position designed to cut off benefits, and it has to accommodate the specific limitations. Document the details of any offer and the claimant’s response at intake.

Why Employment Law Context Matters in Workers’ Comp

Workers’ comp claims don’t exist in a vacuum. The claimant may also have FMLA leave running concurrently. They may have an ADA accommodation request pending. They may have been fired in a way that implicates wrongful termination under state employment law. Your intake form should capture enough employment-law context to spot these overlapping claims—not to litigate them on the comp side, but to identify them so you can either handle them or refer them out before deadlines expire.

A dedicated workers’ comp intake form, built for the administrative system and its particular requirements, captures all of this in a structured, consistent way. It ensures your paralegals are asking the right questions, your attorneys are getting complete files from day one, and nothing falls through the cracks because a generic form didn’t have a field for it.

You can browse our full library of profession-specific legal intake forms and questionnaires in the Templateez shop—every form is fillable, professionally formatted, and ready to deploy.