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

[text* your-name class:suba placeholder "FULL NAME"]

DOB: [date your-birth class:suba placeholder "BIRTH DATE"]

SSN: [text your-ssn class:digits placeholder "SSN"]

<p>SEX: </p>
[select gender class:suba "Male" "Female"]

[email your-email class:suba placeholder "EMAIL ADDRESS"]

[text your-carrierf class:suba placeholder "CARRIER FILE NO."]

[text your-street class:suba placeholder "STREET"]

[text your-city class:suba placeholder "CITY"]


[select your-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number your-zip min:5 class:sub placeholder "ZIP CODE"]

[text date-in class:suba placeholder "DATE OF INJURY"]

[text file-type class:suba placeholder "FILE TYPE"]

<p>WC </p>

[select Iamthe4 class:suba "YES" "NO"]

<p>OCCUPATIONAL</p>

[select Iamthe3 class:suba "YES" "NO"]


<p>LONGSHORE</p>

[select Iamthe1 class:suba "YES" "NO"]

<p>VOCATIONAL</p>

[select Iamthe2 class:suba "YES" "NO"]


[textarea your-notes class:suba placeholder "NOTES"]

[textarea list-body1 class:suba placeholder "Non-related work injury/condition: "]

[textarea list-body2 class:suba placeholder "Description of work injury: "]


[textarea list-body3 class:suba placeholder "Other Comments: "]

[number your-phone class:digits placeholder "PHONE NUMBER"]

[text your-employ class:suba placeholder "EMPLOYER NAME"]



<h3 class="heading3">CLAIMANT ATTORNEY </h3>
[text cla-name class:suba placeholder "CLAIMANT ATTORNEY NAME"]
[text cla-street class:suba placeholder "CLAIMANT ATTORNEY STREET"]
[text cla-city class:suba placeholder "CLAIMANT ATTORNEY CITY"]
[select cla-satate class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]


[number cla-zip min:5 class:sub placeholder "CLAIMANT ATTORNEY ZIP CODE"]
[email cla-email class:suba placeholder "CLAIMANT ATTORNEY EMAIL ADDRESS"]
[number cla-phone class:digits placeholder "CLAIMANT ATTORNEY PHONE NUMBER"]
[number cla-fax class:suba placeholder "CLAIMANT ATTORNEY FAX NUMBER"]

<h3 class="heading3">ADJUSTOR</h3>
[text adjustor-name class:suba placeholder "ADJUSTOR NAME"]
[text adjustor-tpa class:suba placeholder "CARRIER/TPA/SERVICING AGENT"]
[text adjustor-street class:suba placeholder "ADJUSTOR STREET"]
[text adjustor-add class:suba placeholder "ADJUSTOR ADDRESSS"]
[text adjustor-city class:suba placeholder "ADJUSTOR CITY"]

[select adjustor-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number adjustor-zip min:5 class:sub placeholder "ADJUSTOR ZIP CODE"]
[email adjustor-email class:suba placeholder "ADJUSTOR EMAIL ADDRESS"]
[number adjustor-phone class:digits placeholder "ADJUSTOR PHONE NUMBER"]
[number adjustor-fax class:suba placeholder "ADJUSTOR FAX NUMBER"]

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

[text deffenseattorney-name class:suba placeholder "DEFENSE ATTORNEY NAME"]
[text deffenseattorney-firm class:suba placeholder "DEFENSE ATTORNEY FIRM"]
[text deffenseattorney-street class:suba placeholder "STREET"]
[text deffenseattorney-city class:suba placeholder "DEFENSE ATTORNEY CITY"]

[select deffenseattorney-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number deffenseattorney-zip min:5 class:sub placeholder "DEFENSE ATTORNEY ZIP CODE"]
[email deffenseattorney-email class:suba placeholder "DEFENSE ATTORNEY EMAIL ADDRESS"]
[number deffenseattorney-phone class:digits placeholder "DEFENSE ATTORNEY PHONE NUMBER"]
[number deffenseattorney-fax class:suba placeholder "DEFENSE ATTORNEY FAX NUMBER"]



[submit class:btn-submit "SUBMIT"]