Please provide the following details for your workers compensation benefits case. Thank you.

First Name   Last Name

Address

City State
Zip

Phone

E-mail

Age

Have you filed a Massachusetts workers compensation claim in the last 18 months? Yes No

Was your claim denied? Yes No

Have you visited a doctor in the last 12 months for your condition? Yes No

Is the injury work related? Yes No

How long have you worked at this job?

Are you currently working? Yes No

Are you now receiving or have you received Social Security disability payments? Yes No

What is your Disability/ Medical condition?

How were you hurt at work?

Date of your work injury/illness

Where did you work when you were injured?

Submit free case evaluation to Fitzpatrick & Associates Workers Compensation Lawyers Group

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Potential clients: Please be advised that submitting this Free Case Evaluation form through this on-line web site does not create an attorney-client relationship. An attorney-client relationship is formed and confirmed only after a fee agreement is signed and dated by us and you. This free evaluation form will be reviewed by an attorney and someone from Fitzpatrick & Associates will contact you to discuss the facts of your potential case.