By the Templateez Team · Licensed Attorney · June 2026

Workers' Comp Intake Forms: Every Field Your Firm Needs From Day One

Workers' compensation cases live and die on dates. The date of injury. The date it was reported to the employer. The date the claim was filed with the carrier. The date the statute of limitations runs. Miss any of these at intake, and you are playing catch-up for the life of the case — or worse, you realize three months in that the statute already ran and you are looking at a malpractice problem.

A structured intake form does not just collect information. It forces the right questions in the right order so that by the time a potential client leaves your office — or hangs up the phone — you know whether you have a case, what the deadlines are, and what documentation you need to chase immediately.

Date of Injury vs. Date Reported: Two Different Fields

These are not the same thing, and your intake form must treat them separately. The date of injury is when the accident happened or when the occupational disease manifested. The date reported is when the employee told their employer about it. In many states, a gap between these two dates triggers specific legal consequences.

For traumatic injuries, the date is usually clear — the worker fell off a scaffold on March 12th. For repetitive stress injuries or occupational diseases, it is far murkier. A factory worker who develops hearing loss over ten years does not have a single date of injury. Carpal tunnel from years of assembly-line work does not have an incident date. Your form needs to accommodate both types:

• Date of injury or first symptom
• Is this a single incident or a repetitive/cumulative injury?
• Date the injury was reported to the employer
• How it was reported (verbal, written, incident report filed)
• Who was the report made to (supervisor name and title)

In states like New Jersey, the employee has 90 days from the date of the accident to provide notice to the employer, but the claim petition must be filed within two years of the accident date. In New York, the notice window is 30 days and the claim filing deadline is two years. These numbers vary by state, and the dates on your intake form are what you use to calculate them.

Employer Information: More Than Just the Company Name

Workers' comp is an employer-specific system. You need the employer's legal name (which may differ from the name on the building), address, phone number, and the name of the supervisor at the time of injury. You also need the workers' compensation insurance carrier — not the employer's general liability insurer, the comp carrier specifically.

Capture these employer details:

• Employer legal name and address
• Department or division where the injured worker was employed
• Supervisor name, title, and direct phone number
• Workers' compensation insurance carrier name
• Claim number (if one has been assigned)
• Employer's third-party administrator (TPA), if applicable
• Date the employee started working for this employer
• Job title and a brief description of normal job duties

The job title and duties matter because they define what "light duty" means later. A warehouse worker whose normal duties involve lifting 50-pound boxes has very different light-duty restrictions than an office worker who sits at a desk. If the employer offers modified duty, you need to evaluate whether it actually fits within the medical restrictions — and that analysis starts with knowing what the claimant's regular job entailed.

Treating Physician and Medical Treatment Timeline

Workers' comp medical treatment follows specific rules that differ from regular health insurance. In many states, the employer or its carrier has the right to direct medical care, at least initially. Your intake form needs to capture:

• Name of the treating physician (the doctor currently managing the case)
• Was the doctor chosen by the employee, directed by the employer, or assigned by the carrier?
• Date of first medical treatment for this injury
• Emergency room visit? (Date and hospital)
• Current treatment status: active treatment, maximum medical improvement (MMI), or discharged
• Any surgeries performed or recommended
• Current medications prescribed for the work injury

The treatment timeline is critical for several reasons. First, it establishes whether the injury was taken seriously from the start — a gap of three weeks between the alleged injury and the first doctor visit is something the carrier will use against the claimant. Second, it tells you whether there has been an Independent Medical Examination (IME) by the carrier's doctor, which often triggers a denial or a dispute over ongoing treatment.

Claim Number and Current Claim Status

If the claim has already been filed, capture the claim number. This is the single identifier that lets you pull up the entire file with the carrier or TPA. If no claim has been filed yet, that is a red flag — find out why and whether the statute is about to run.

Ask about the current claim status:

• Has a workers' comp claim been filed? (Yes/No)
• If yes: claim number, date filed, and with which carrier
• Is the claim accepted, denied, or pending?
• If denied: reason for denial (if the claimant received a denial letter)
• Is the claimant currently receiving temporary disability benefits?
• Has the claimant returned to work? Full duty, light duty, or not at all?

A denied claim tells you the fight is already on. A pending claim tells you there is still time to influence the outcome. An accepted claim with an ongoing dispute over benefits tells you the case is about the scope of compensation, not liability. Each scenario requires a different litigation strategy, and your intake form should surface the distinction immediately.

Prior Workers' Comp Claims and Pre-Existing Conditions

The carrier will investigate prior claims. Your intake form should get there first. Ask directly whether the claimant has ever filed a workers' compensation claim before — with any employer, in any state. For each prior claim, capture the date, employer, body part injured, and outcome.

Pre-existing conditions to the same body part are the most common defense in contested comp cases. A current back injury claim is much harder to win if the claimant had a prior back injury claim five years ago. That does not make the current claim invalid — but it changes the medical evidence you need and the arguments you will face.

Also ask about non-work-related medical history for the affected body part. A claimant with a prior car accident that injured the same knee is going to face a causation argument from the carrier. Knowing about it at intake lets you address it proactively with the treating physician rather than getting ambushed at a deposition.

This causation overlap is familiar if your firm also handles personal injury cases. The same pre-existing condition that complicates a comp claim can be relevant in a third-party liability action. For a deeper look at the personal injury intake process, see our guide on personal injury intake form essentials.

Light Duty Status and Wage Information

Temporary disability benefits are calculated based on the claimant's average weekly wage. Your intake form needs wage information: hourly rate or salary, average hours per week (including overtime), and whether the claimant had multiple jobs at the time of injury. Many comp claimants work in trades or construction where overtime is significant, and using a base-40-hours calculation dramatically understates their actual wage loss.

On light duty, ask whether the employer has offered modified work, whether the claimant is currently performing modified work, and whether the modified duties actually fall within the medical restrictions. "Light duty" is a term employers use loosely — sometimes it means answering phones, sometimes it means doing the same job but with a 25-pound lifting restriction on paper that nobody enforces. Your form should capture what the modified duties actually involve.

Statute of Limitations Awareness

Your intake form should prompt whoever is conducting the intake to check the statute of limitations immediately. Include a field — even if it is internal-only — that calculates or flags the filing deadline based on the date of injury and the jurisdiction.

In practice, this means your form needs the state where the injury occurred (which may differ from where the claimant lives or where the employer is headquartered). Interstate truckers, construction workers who travel to job sites, and remote employees all create jurisdictional questions that your intake needs to surface.

Our workers' compensation intake form is structured around all of these fields: injury dates, employer and carrier details, treating physician, claim status, prior claims, wage information, light duty status, and statute tracking. Every section described above is built in, organized in the sequence that a comp attorney or paralegal naturally works through during a new client call.

If your firm handles multiple practice areas, the Legal Bundle includes all 38 legal intake form sets — workers' comp, personal injury, employment law, family law, and every other legal specialty in the catalog.