Penney & Associates Workers' Compensation

Advocating the rights of injured workers

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WORKERS' COMPENSATION INTAKE FORM

CLIENT INTAKE INFORMATION

STATUTE OF LIMITATIONS  Please read before filling out the intake form.

Workers' Compensation has a one year statute from the date of injury if no benefits were provided or five years from the date of injury if any workers' compensation benefits are provided.  These time limitations apply to normal benefits.  Additionally, a claim may be filed within one year of the provision of last benefits, and this can act to extend, or to shorten the five year period previously mentioned.

There are other Special Remedies in workers' compensation such as a claim for Serious & Willful Misocnduct on the part of the employer.  You have one year from the date that the Serious & Willful Misconduct took place.  Serious & Willful Misconduct simply means that your employer knew, or should have known, that the potential for a serious injury would exist by his intentionally ignoring such things as: (a) known faulty equipment, (b) known broken machinery, (c) failure to provide proper training or safety programs which lead to an injury, etc.  In addition, Labor Code Section 132(a) prevents an employer from discriminationg against you because you file, or inform the employer that you may file, for workers' compensation benefits.  There is a one year time limit to file this penalty.

If you think your injury was the fault of a third party, such as a motor vehicle accident while you are on the job, you may have a civil action against that third party in addition to your workers' compensation claim.  There is a two year statute for filing a civil action.

If you are filing a civil action against a public entity, such as a police department or other government agency, the time limit you have to file a lawsuit is only 6 months.

The filling out of the form below does not mean that we are representing you in your case.  Unless you have a signed fee agreement from our office, we do not represent you.

Unless otherwise indicated, when we accept your workers' compensation case, we do not automatically agree to represent you in any other matter. If you feel that you have a claim for benefits under any of these circumstances, we strongly suggest that you seek the immediate advice of an attorney to protect your rights.

 

Please fill out the entire form.  This is a secure site and no information will be given to any other party.

By pressing the send button below, you acknowledge that you have read the Statute Of Limitations at the top of this page

First Name
Middle Name
Last Name
Company Name
Address Line 1
Address Line 2
City
State
Zip Code
Country
Daytime Phone() -
Evening Phone() -
Fax() -
E-mail Address
Date of Birth
Social Security Number
Employer Name
Employer Address
Date of hire
Job Title
Wages at time of injury
Hours worked per week
Body parts affected
Date reported to employer
Reported to whom
Did you receive a claim form?
When did you return it to employer?
Did your employer send you to a doctor?
When?
Name of doctor you were sent to
Address of doctor
Workers Comp Insurance company
Insurance company address
Insurance company phone
Claim number
Adjuster
Are receiving benefits from the insurance company?
Are you receiving benefits from State Disability?
Who is your treating physician?
List all doctors you have seen in the last 5 years
Were you fired or discriminated against?
Was anyone else responsible for your injury?
Were you injured due to faulty equipment?
Give a brief description of how your injury occured
Are you now, or have you been represented by an attorney for this injury?
If so, please give the name, address and phone number of the attorney