Worker’s Comp Questionnaire Worker's Comp Questionnaire Name First Middle Last Spouse's Name First Middle Last Children's names and ages Add RemoveI.E. John Smith (age 12)Work Schedule prior to injury Pay rate prior to injury Position/Title Date of hire MM slash DD slash YYYY Section BreakWC insurance company's name WC insurance adjuster's name WC insurance adjuster's phone number WC insurance adjuster's email address WC insurance claim # State file # Describe in detail how you were injuredWhat is your current diagnosis? Who did you report your injury to? What Date? Was there a witness to the incident? If yes, who? Did you complete any forms for your employer and/or insurance company describing the incident? Did you give a recorded statement or conduct and interview with the insurance adjuster? If yes, when? Current health insurance info (e.g. BCBS, VHAP, Medicare, Medicaid, etc…) Policy # Phone # Has your health insurance paid for any treatment related to your work injury? Have you had a similar prior injury at any time? If yes, when: List all other medical conditions in the past 5 years: Add RemoveHave you filed any prior WC claims? Identify the injury & date of any past claim(s): Add RemoveHave you ever been arrested or charged with a crime? Identify date & charge: Add RemoveHave you received unemployment compensation for any period of time since your injury? If yes, during what time period? Do you have Facebook, Twitter, Instagram, Snapchat, or other social media accounts? Δ
