• 801-424-WORK (9675)

Workers’ Compensation Case Questionnaire

*Please complete the following questions to the best of your ability. We understand that there may be a need to change or add information at a later time.

Include State Disability, Unemployment, Social Security, Long Term Disability, Retirement/Pension, or any other source of benefits.
Heart disease, arthritis, etc.

By sending us your completed questionnaire, you will be asking us to look at your case and to consider representing you. Sending us a completed questionnaire does NOT mean that we will take your case. All communications from you to us will be kept strictly confidential regardless of whether we become your attorneys.

Please also be aware that sending us a completed questionnaire does not mean that we will take any action to preserve your rights or to file a timely claim or lawsuit unless we accept your case and agree to represent you.

All legal claims have time limits for filing. It is always wise to seek the opinion of a qualified, competent attorney as soon as possible after an injury occurs so that evidence may be gathered and preserved, and important deadlines can be met in order to hold all responsible parties accountable.

By clicking “I Accept,” you confirm that you have read the terms and conditions stated above, and that you agree to be bound by them.