a:9:{s:6:"active";b:1;s:7:"subject";s:64:"Manley & Associates "Workers Compensation Claim" Form Submission";s:6:"sender";s:47:"[your-name] <wordpress@manleyandassociates.com>";s:9:"recipient";s:25:"nformisano@bmanleymsa.com";s:4:"body";s:2986:"From: [your-name] <[your-email]>

<h3 class="heading3">INFORMATION</h3>

Full name: [your-name]

Firm name" [your-firm]

Mailing Address: [your-address]

City: [your-city]

State: [your-state]

Zip: [your-zip]

Email Address: [your-email]

Phone Number: [your-phone]

Fax: [your-fax]

I am the: [Iamthe]

<h3 class="heading3">CLAIMANT</h3>

Claimant's name: [claimant-name]

Gender: [gender]

Claim File Number: [claim-file]

Claimant Address: [claimant-add]

Claimant City: [claimant-city]

Claimant State: [claimant-state]

Claimant Zip: [claimant-zip]

Date of Birth: [d-ob]

Social Security Number: [social-sn]

All Dates of Injuries to be included in the MSA and Settlement: [dates-injur]

State of Jurisdiction: [state-oj]

SSDI Beneficiary? [SSDIBeneficiary]

Date Medicare Eligible: [date-medi]

Settlement Agreement: [settlement-agreement]

Non-covered Body Parts and Conditions: [non-cover]

Covered Body Parts and Conditions: [cover]

Brief description of injury: [brief-des]

Gaurdian Appointed? [GuardianAppointed]

Other comments: [Othercomments]

<h3 class="heading3">EMPLOYER</h3>

Employer: [employer-name]

Employer Address: [employer-add]

Employer City: [employer-city]

Employer State: [employer-satate]

Employer Zip: [employer-zip]

Employer Phone: [employer-phone]

<h3 class="heading3">CLAIMANT ATTORNEY</h3>

Claimant Attorney Name: [ClaimantAttorney-name]

Claimant Attorney Firm: [ClaimantAttorney-firm]

Claimant Attorney Address: [ClaimantAttorney-add]

Claimant Attorney City: [ClaimantAttorney-city]

Claimant Attorney State: [ClaimantAttorney-state]

Claimant Attorney Zip: [ClaimantAttorney-zip]

Claimant Attorney E-mail: [ClaimantAttorney-email]

Claimant Attorney Phone: [ClaimantAttorney-phone]

Claimant Attorney Fax: [ClaimantAttorney-fax]

<h3 class="heading3">ADJUSTOR</h3>

Adjuster Name: [adjuster-name]

Adjuster Firm: [adjuster-firm]

Adjuster Address: [adjuster-add]

Adjuster City: [adjuster-city]

Adjuster State: [adjuster-state]

Adjuster Zip: [adjuster-zip]

Adjuster E-mail: [adjuster-email]

Adjuster Phone: [adjuster-phone]

Adjuster Fax: [adjuster-fax]


<h3 class="heading3">DEFENSE ATTORNEY</h3>

Defense Attorney Name: [deffenseattorney-name]

Defense Attorney Firm: [deffenseattorney-firm]

Defense Attorney Address: [deffenseattorney-address]

Defense Attorney City: [deffenseattorney-city]

Defense Attorney State: [deffenseattorney-state]

Defense Attorney Zip: [deffenseattorney-zip]

Defense Attorney Email Address: [deffenseattorney-email]

Defense Attorney Phone: [deffenseattorney-phone]

Defense Attorney Fax: [deffenseattorney-fax]

<h3 class="heading3">AVAILABLE SERVICES</h3>
<p>All checked boxes for the requested services:<br>
[checkbox-496]
[checkbox-497]
[checkbox-498]
[checkbox-499]
[checkbox-500]
[checkbox-501]
[checkbox-502]
[checkbox-503]
[checkbox-504]
[checkbox-505]
[checkbox-506]
[checkbox-507]

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