north carolinasouth carolina
Workers' Compensation Submission Form

   We are anxious to help you.  There are two ways you can contact us about your case.  You can either call us at 1.800.556.8404 to talk to one of our client service representatives or you can fill out the on-line form below and submit it to us from this website at any time.  After completing the form you may submit it by simply clicking on the I AGREE button after reading our necessary disclaimer. 



Personal Information

Your last Name   Your First Name   Your Gender  

Physical Address (Include City, State, Zip)  
Email Address    
Cell Phone (xxx-xxx-xxxx)   Home Phone (xxx-xxx-xxxx)   Work Phone (xxx-xxx-xxxx)  

 

Accident Information

Employer (when injured):  
Your Job title/Job you held:  
Length of time employed

 
Hours worked per day
 
Days worked per week

 
Hourly rate of pay



 
Date of accident:  
Did you notify management of injury?
 
Date person notified:  
Total time missed from work due to the injury:



 
Date first missed work?  
Have you been paid anything for your injury(ies)?
 
If yes, when did you first receive payments?  
Are you now receiving disability payments?
 
If so, how long have you received disability payments?



 
Amount of disability payments per month:  
Place of Accident: City:
State:
Description of Accident & Injury (optional):
Did your accident on the job: (check any that apply)





Did someone other than your employer or a fellow employee cause your injury?
 
Have you returned to work?
 
Date of return:  
Did you return to your pre-accident position?
 
If not, did your new position result in less pay?
 
Have you given a recorded or written statement about the accident?
 
Do you have any previous Workers Compensation claims?
 
Have you viewed our tutorial on harassment/discrimination?
 
Are you presently represented by an attorney?
 

 

Disclaimer
WARNING:
If you are a Pre-Paid Legal Services, Inc. Member you may not use this method of seeking legal assistance. You must call the 1.800 number on your membership card. If you submit a request in this manner we will not be able to process you as a Pre-Paid Legal member which could result in significant delays.
     
Disclaimer:    
Before you can submit your case for potential review, you must read and agree to the following: "I understand that by submitting this information to MFWWC, I have not created an attorney/client relationship with MFWWC and that MFWWC has no responsibility to protect my interests in this matter in any way unless and until I enter into a signed, written fee agreement with MFWWC. I understand that MFWWC has no obligation to reply to this email and are not responsible for this matter. By clicking on the I Agree button below, I hereby submit my information on this basis and certify that I have read the GENERAL Disclaimer."  





  When you need legal help, we are here to serve you.