DIHAC

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Workers Compensation

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Have you been injured on the job within the last 3 years?

Did your injury occur as a result of a defective or dangerous condition on your employer’s property?

Were you injured as a result of the actions, conduct or behavior of a co-worker or another employee of your company?

Did you injure yourself on a tool, equipment or instrument owned by your employer?

Did you report your injury to your employer?

Was your injury investigated?

Were you seen by a doctor, hospital or medical facility within 24 hours of your injury?

Have you been diagnosed with a medical condition as a result of the injury you sustained on the job?

Have you undergone any diagnostic testing, such as, an x ray, MRI, or CT scan, that has positively identified your injury or medical condition?

Has any doctor recommended surgery to repair or correct the injury that you sustained on the job?

Have you ever seen a doctor or medical professional for a similar injury or medical condition in the past?

Has any doctor issued a disabled you from working at your job as a result of the injury you suffered at work?

What best describes the amount of time you have lost at work as a result of your injuries (Choose 1 only):

Is your injury of a permanent nature?

What best describes your ability to return to work?

What best describes your income or wage rate?

Do you have unpaid medical expenses as a result of the injury you suffered on the job?

What best describes the amount of your medical expenses?

Does your employer carry workers compensation insurance?

Have you filed a petition (dispute) for workers compensation benefits with the Workers Compensation Bureau?

Has your workers compensation claim been:

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