Request for Services Form -

Request For Services Form

Fill in the fields below as best you can to have one of our consultants contact you regarding your issues with WCB and to see if we can help!

Name *

First

Last

Phone Number *

-

Email *

Do you Currently Have a Representative/ Lawyer/ Advocate? *

Yes No Other Unknown

Do You Have Any Other WCB Claims Past or Present? *

Yes No Unknown

If Yes, Please List the Claim Number/ Date of Accident/ and Injury *

Do You Have Any Active Appeals at This Time? *

Yes No Unknown Other

Was Your Current Claim Accepted by WCB? *

Yes No Unknown Other

If Yes, What is Your Claim Number? *

Date of Accident *

Please list exact date if possible (Day, month, and year)

Place of Accident *

Details of Accident *

Type of Injury *

Sprain/ Strain Fracture Crush Injury Head Injury Industrial Disease Amputation Other

Select all applicable injuries to the accident

Injured Body Part(s)? *

Additional Information *

(ie. Age, Treatments or Surgeries, Work Status, etc.)

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