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Workers Compensation Intake

First Name

Employer/ company at time of injury?

Last Name

Are you still employed at this company?

Date of Injury * required

BWC Claim Number:

Is there a managed care company ?

Name of MCO:

MCO Phone Number:

Have you retained an attorney?

Attorney Name:

Attorney Phone Number:

Have you missed work?

If yes, please list all dates

Job Description?

Were you transported to the emergency room?

Name of emergency room?

I confirm that the information given in this form is true

1038 South Washington St. Millersburg OH 44654
P: 330.674.4373 F:330.556.4086

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