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.