Workers’ Compensation Intake Forms & Client Questionnaires

The Clock Starts Before the Client Calls You

Workers' compensation cases are driven by deadlines that start running before the injured worker even thinks about hiring an attorney. In most states, the employee has 30 to 90 days to provide written notice of injury to the employer, and the statute of limitations for filing a claim petition can be as short as one year from the date of injury or last payment of compensation. By the time the call comes in, days or weeks of that window may already be gone. The intake must immediately capture the date of injury, the date the injury was reported to the employer, and whether a written incident report was filed. If there is a gap between when the injury occurred and when it was reported, you need the reason for the delay documented at intake because the carrier will use that gap to deny the claim. These fillable PDF workers' compensation intake forms are designed by a licensed attorney to capture every critical fact from the first phone call.

Employer Information and Insurance Carrier Details

The employer's identity in a workers' comp case is not always straightforward. Was the injured worker a W-2 employee or an independent contractor? If they were classified as an independent contractor, was the classification legitimate or is there a misclassification issue that opens the door to a comp claim? Who is the actual employer versus the general contractor, the staffing agency, or the labor broker? The intake needs the employer's legal name, address, the supervisor's name and contact information, the workers' compensation insurance carrier (if known), and the policy number. If the employee was working through a temp agency, you need both the agency and the host employer's information. Whether the employer has more or fewer than a certain number of employees matters for coverage requirements in many states. The intake form also captures whether the employer has offered light-duty work, whether the employee is currently working in any capacity, and whether there have been any retaliatory actions since the injury was reported.

Injury Details and Mechanism of Injury

The mechanism of injury determines the trajectory of the entire case. A traumatic injury with a specific date and event, such as a construction worker who fell from scaffolding on a particular Tuesday morning, is a fundamentally different intake than an occupational disease claim where a factory worker developed bilateral carpal tunnel syndrome over fifteen years of repetitive assembly work. The intake must capture the specific body parts injured, the mechanism (slip and fall, struck by falling object, caught in machinery, motor vehicle accident during work, repetitive stress, chemical or toxic exposure), whether the injury was witnessed and by whom, and the immediate medical treatment received. Did the worker go to the emergency room? Were they sent to the company's occupational health clinic? Did they see their own doctor? The first medical provider's records become critical evidence, and the intake captures who that provider was and when the first visit occurred. For the warehouse worker who hurt his back lifting a box but kept working for three weeks before seeking treatment, you need to document every day he worked in pain and whether he reported the injury verbally to anyone during that period.

Medical Treatment, Disability Status, and Wage Information

The medical picture in a comp case is everything. The intake must capture the treating physician's name and specialty, all diagnostic testing performed (MRI, EMG/NCV, X-rays, CT scans), the current diagnosis, any surgeries performed or recommended, current medications, and whether an independent medical examination has been scheduled or already conducted by the carrier's physician. The distinction between temporary total disability, temporary partial disability, and permanent partial disability determines the benefit rate and duration, so the intake captures the current work status: Is the claimant out of work entirely? On light duty? Working full duty but still treating? The average weekly wage calculation drives the benefit amount, and the intake needs to capture gross wages, overtime, tips, bonuses, and the number of weeks worked in the year before the injury. Prior claims with the same or different employers must be documented because they affect apportionment and credibility. If the claimant had a prior back injury claim five years ago and is now claiming a new back injury, the carrier will argue it is a recurrence rather than a new injury, and the intake needs the full history to prepare for that defense.

Claim Status and Proceedings

Many workers' comp clients come in after the claim has already been filed, accepted, and then disputed at some stage. The intake captures the current procedural posture: Has a claim petition been filed? Is the claim accepted for certain body parts but denied for others? Has the carrier filed a utilization review denying a requested surgery? Is there a hearing scheduled, and if so, when and before which workers' compensation judge? Has the claimant received any benefits, and if so, what type and for how long? If benefits were terminated, when and on what basis? Was there a notice of intention to suspend or modify benefits? For claims involving third-party liability, such as a construction site injury where a subcontractor's negligence contributed to the accident, the intake must identify all potentially liable third parties because a third-party personal injury action runs parallel to the comp claim and affects the carrier's subrogation rights.

Our Workers' Compensation Intake Form & Client Questionnaire set is available for $19.99 (complete set), $14.99 (intake form only), or $9.99 (client questionnaire only). Every form is a fillable PDF designed by a licensed attorney who handles workers' compensation claims.