Issue link: http://www.e-digitaleditions.com/i/83215
Claimant's Information: Name: __________________________________________________________ Phone No.: _______________________________________________________ Address : ________________________________________________________ Date of Birth: ______________________ Age:__________ Social Security No.: ________________________________________________ Claimant's Attorney's Information (unless pro se): Name: __________________________________________________________ Firm Name: _____________________________________________________ Address: ________________________________________________________ Phone No.: _______________________________________________________ Employer Information: Name: __________________________________________________________ Address: ________________________________________________________ Insurer Information: Carrier: ________________________________________________________ Adjuster: ________________________________________________________ Adjuster's Phone No.: _____________________________________________ Claim No.: ______________________________________________________ Claim Information: Date of Accident: ________________________________________________ How injury occurred (include body parts injured): ___________________ ________________________________________________________________ Average weekly wage at time of accident: ____________________________ Was claim accepted: ____ YES ____ NO