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Permanent and Total Incapacity Benefits
If you are totally and permanently unable to do any kind of work as a result of a work-related injury or illness you may be entitled to permanent benefits. You can receive these benefits for as long as you are unable to work. You do not have to exhaust your temporary benefits before applying for permanent benefits.You will get two-thirds of your average weekly wage (or a minimum of 20 percent of theSAWW) based on the 52 weeks prior to your injury, up to a maximum of the SAWW.

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 Permanent and Total Incapacity 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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