Gruhin & Gruhin Certified Workers' Compensation Specialist Attorney
WORKERS' COMPENSATION INQUIRY FORM If you would like to be contacted please complete the entire form
*Workers' Comp Inquiry Form* Your name:
Your email address:
Your Telephone Number & Area Code: Ohio County in which the work injury took place:
Ohio County in which you live:
Date of accident: *Enter Accident month* January February March April May June July August September October November December *Enter Date of Accident* 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 *Enter Year of Accident* 1999 2000 2001 2002 2003 2004 2005 2006
Time of accident: 1 2 3 4 5 6 7 8 9 10 11 12 : AMPM
Was anyone injured in the accident ?
I was injured My Co-Workers were Injured More People Were Injured
As a result of my work injury, I had a:
Head Injury Neck Injury Back Injury Knee Injury Hand Injury Wrist Injury Elbow Injury Carpal Tunnel Syndrome Injury Reflex Sympathetic Dystrophy Syndrome Injury Loss of Hand Injury Loss of Finger Injury Loss of Foot Injury Loss of Toe Crushed Hand Injury Crushed Finger Injury Crushed Foot Injury Crushed Leg Injury Crushed Body Injury It's Much More Complicated than anything listed
Please describe the accident & injuries in as much detail as possible:
Please note: You must be a resident of The State of Ohio or you must have been involved in a work accident in the State of Ohio in order for us to respond to this inquiry.
__________________________________________________________________ Please note that this transmission does not create an attorney-client relationship. Pursuant to Ohio Law, Gruhin & Gruhin does not represent anyone in a contingency matter without a signed contract for legal services. Answers provided to any *email legal inquiries* are provided as general information only. If you need legal advice for a specific legal problem, dealing with an Ohio injury claim, an in depth consultation is necessary. Please call or email to schedule a free initial consultation so that we can discuss the complete event & review any relevant papers. __________________________________________________________________ This form is the property of Gruhin & Gruhin, Attorneys Unauthorized use or duplication is forbidden © 2000-2001