Winston Salem: 336-724-2828 / Charlotte: 704-707-3705 info@emplawfirm.com

Workers Compensation Law Questionnaire 

Please complete all areas.

Name*

Email*

Address*


Home Phone*

Cell Phone*

Employer*

Date of Injury*

Description of how the injury occurred: *

Physical injuries suffered: *

Medical treatment received: *

Time missed from work because of injury: *

Wages per hour or per week: *

Date of Birth*

Place of Birth: *

Has your employer accepted or denied your claim?*