Workmans Compensation Claims and Settlements

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	Death Benefits Partial Incapacity Benefits Permanent and Total Incapacity Benefits Permanent Loss of Function and Disfigurement Temporary Total Incapacity Benefits


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Death Benefits
Reasonable burial expenses up to $4000 will be paid in cases where the injury results in death. Surviving spouses can receive weekly benefits equal to two-thirds of the deceased worker's average weekly wage, up to a maximum of the SAWW. They can receive these benefits for as long as they remain dependent and do not remarry. Surviving spouses become eligible for yearly cost of living increases two years after the date of injury. If the spouse remarries, $60 a week is paid to each eligible child. The total weekly amount paid to dependent children can not exceed the amount the spouse had been receiving.

Filing a workers' compensation claim is a complicated and difficult task. If you would like your claim to be reviewed by an attorney, complete the form below for a free evaluation.

Free Death Benefits Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
City where accident occured:	*
State where accident occured:	*

Please briefly explain the incident that caused the injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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understanding the facts of your case?

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