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Workers Compensation Intake
First Name
Employer/ company at time of injury?
Last Name
Are you still employed at this company?
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Date of Injury
BWC Claim Number:
Is there a managed care company ?
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Name of MCO:
MCO Phone Number:
Have you retained an attorney?
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Attorney Name:
Attorney Phone Number:
Have you missed work?
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If yes, please list all dates
Job Description?
Were you transported to the emergency room?
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Name of emergency room?
I confirm that the information given in this form is true
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