Workers' Compensation Information

New York Workers' Compensation Contact Form

Name

E-mail Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

What date and time were you injured?

For whom were you working?

Describe the work-related activity in which you were engaged at the time of your injury.

How did the injury occur?

Were your injuries caused by any tool/equipment failure?
Yes No

If your injuries were caused by a tool/equipment failure, who sold, distributed and/or manufactured the equipment?

What date and time did you first seek medical care for your injury?

What was/is your diagnosis and prognosis, including a description of your symptoms and recommended treatment?

Who is your physician?

Had you experienced similar symptoms prior to the date of your accident?
Yes No
If so, when?

Did the accident exacerbate a pre-existing injury?
Yes No

Has your doctor authorized you to return to work?
Yes No

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