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

Worker's Comp Questionnaire

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

Section Break

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: