New SSD Client Information Form
Please Enter "N/A" for Fields that do not Pertain to You!
Have you already spoken to someone in our office?
How did you hear about us?
Please select today's date.
WCB # for this Case
Social Security Number
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Date of Birth
Place of Birth
Do you have any children under the age of 18?
Do you speak English?
If no, which language do you speak?
Can you read English?
Highest degree of education?
If other, please describe:
Can you write in English?
Military Service Prior to 1968
Date Last Worked
Were you self-employed?
Job History Last 15 Years
Your Injury or Illness
Illnesses, injuries, conditions that limit your ability to work
Were your illnesses, injuries, or conditions related to work?
Have you filed or intend to file for workers' compensation benefits?
Return to Work
Have you returned to work?
If yes, on what date?
If you returned to work, who are you working for now?
Medical Treatment for this Injury
What was the date of your first treatment?
Where did you first receive treatment?
Name, Address, Phone & Fax of the Doctor(s) Treating you for this Injury, condition, or Illness
Have you had any testing done? Please list all that apply.
Is another attorney presently working on this claim?
If none, enter Not Applicable