a:9:{s:6:"active";b:1;s:7:"subject";s:73:"[claimant-name] Manley & Associates "Worker’s Compensation Intake Form"";s:6:"sender";s:47:"[your-name] <wordpress@manleyandassociates.com>";s:9:"recipient";s:61:"lawatson@bmanleymsa.com, msareferrals@manleyandassociates.com";s:4:"body";s:2928:"From: [your-name] <[your-email]>

FORM TYPE: Worker's Compensation Claim

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

Your Name:
[your-name]

Your Firm:
[your-firm]

Your Address:
[your-address]

Your City:
[your-city]

Your State:
[your-state]

Your ZIP:
[your-zip]

Your Email:
[your-email]

Your Phone:
[your-phone]

Your Fax:
[your-fax]

I am The:
[Iamthe]


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

Claimant 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:
[social-snn]

State of Jurisdiction:
[state-oj]

SSDI Beneficiary:
[SSDIBeneficiary]

Date Medicare Elligible:
[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]

Guardian Appointed:
[GuardianAppointed]

Other Comments:
[Othercomments]


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

Employer Name:
[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 Email:
[ClaimantAttorney-email]

Claimant Attorney Phone:
[ClaimantAttorney-phone]

Claimant Attorney Fax:
[ClaimantAttorney-fax]


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

Adjustor Name:
[adjuster-name]

Adjustor Firm:
[adjuster-firm]

Adjustor Address:
[adjuster-add]

Adjustor City:
[adjuster-city]

Adjustor State:
[adjuster-state]

Adjustor Zip:
[adjuster-zip]

Adjustor Email:
[adjuster-email]

Adjustor Phone:
[adjuster-phone]

Adjustor 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:
[deffenseattorney-email]

Defense Attorney Phone:
[deffenseattorney-phone]

Defense Attorney Fax:
[deffenseattorney-fax]

CHECKED AVAILABLE SERVICES:
[checkbox-496]
[checkbox-497]
[checkbox-498]
[checkbox-499]
[checkbox-500]
[checkbox-501]
[checkbox-502]
[checkbox-503]
[checkbox-504]
[checkbox-505]
[checkbox-506]


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