LEVITTE LAW GROUP

Workers' Compensation Third Party Free Evaluation Form (* denotes required fields)

Title: 
*First Name: M.I.: *Last name: 
*Address Street: 
 *City: *State: Zip Code: 
Phone: (xxx xxx xxxx) Best time to contact you? 
Email: 
Is this inquiry is not for your self please tell us relationship to injured: 
If this inquiry is not for your self, please provide name of injured 
First Name: Last Name: 
Injured Date of Birth: (mm/dd/yyyy) When did injury occur? (mm/dd/yyyy) 
Where did injury occur? City: State: 
What are the injuries: 
If other please describe the injuries: 
What happened: 
Does injured receiving benefits: Weekly rate: 
How long is injured out of work: (in days) 
Has physician released injured to work in any capacity: 
Has physician advised that injured have sustained permanent injury: 
Was the injured hospitalized overnight: 
What is the name of the company injured work for: 
What is the name of injured insurance carrier: 
Do injured currently receiving treatment: 
What treatment have injured received: 
Do injured currently has an attorney: 
Please briefly describe your legal or any other concerns: 
 

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 I understand that submitting this form does not create an attorney client relationship.   

Old City Hall, 45 School St. Boston MA 02108 | Phone 617 227 1792 | Fax 617 227 9294 | Levitte Law Group