Consultation Form: Ohio Lawyers: Larrimer and Larrimer Attorneys serving Columbus

Your Name:
Your Street Address:
Your City/ State/ Zip:
Your Phone Number:
Your Email:
Bureau of Workers’ Compensation Claim #:
Other BWC Claim #’s:
Date of Injury:
Name of Employer at time of Injury:
Date hired by Employer:
Briefly describe how injury occurred:
Job title & duties on date of injury:
Date of injury wage per hour:
Date of injury hours per week worked:
Name of Present Employer:
Present duties/title:
Current wage per hour:
Current hours per week worked:
Name of current doctor for your BWC injury claim:
Date of most recent visit to your doctor’s office:
Did you receive emergency room treatment at or soon after the injury?		Yes No
If yes, date of treatment and name of hospital:
Before this injury, have you ever been treated for a similar condition by a doctor?		Yes No
If yes, date last treatment occurred:
Name of doctor who treated you:
Did you miss more than 7 days of work because of this injury?		Yes No
If you were off work and are now back to work, list date you returned to work:
Are you off work now?		Yes No
Date you last worked:
Who referred you to Larrimer & Larrimer?
Have you ever been represented by a Workers’ Compensation attorney before?	*	Yes No
If yes, name of attorney:

The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent.

Practice consists of exclusively representing injured workers before the Ohio Bureau of Workers' Compensation and Industrial Commission of Ohio.

Helping injured workers since 1928.

Consultation Form: Larrimer and Larrimer, serving Columbus, Ohio