' Worker's Comp Questionnaire - Larson & Gallivan Law
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Worker’s Comp Questionnaire

Worker's Comp Questionnaire

Spouse's Name
Children's names and ages
I.E. John Smith (age 12)
MM slash DD slash YYYY

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List all other medical conditions in the past 5 years:
Have you filed any prior WC claims? Identify the injury & date of any past claim(s):
Have you ever been arrested or charged with a crime? Identify date & charge: