Use this as a private worksheet
Bring the facts a lawyer needs to understand the file quickly. This is not an official agency or court form.
Claim basics
- ☐ Injury or symptom-start date: ______________________________
- ☐ Date reported to employer: ______________________________
- ☐ Employer and job title: ______________________________
- ☐ Claim administrator/insurer and claim number: ______________________________
Current dispute
- ☐ What changed most recently: ______________________________
- ☐ Next known deadline or hearing date: ______________________________
- ☐ Current medical restrictions: ______________________________
- ☐ Whether wage checks or treatment changed: ______________________________
First-call packet
- ☐ Denial or benefit notice: ______________________________
- ☐ Most recent medical work-status note: ______________________________
- ☐ One-page timeline: ______________________________
- ☐ Pay records or payment ledger: ______________________________
- ☐ Job description or light-duty offer: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.
Use the worksheet with the source records
- Enter dates from the notice, medical record, payment record, or message instead of memory.
- Leave an item blank when it is unknown; do not guess to complete the page.
- Keep a private copy and update it after a new notice, appointment, payment, or work-status change.
- Bring the worksheet and the supporting documents to an agency call or lawyer consultation.