/ 0
60%
Table of contents

Document in text mode:

Life Care Chiropractic & Wellness Center Workman Compensation History Form Patients Name _________________________________________________ Date ________________________ Name of Compensation Carrier ____________________________________ Phone ______________________ Address of Carrier ___________________________ City ____________________ State ____ Zip __________ Employers Name _____________________________________________ Phone ________________________ Employers Address _____________________________________ City __________ State ____ Zip _________ 1. Type of Business ____________________________________ Your Occupation ______________________ 2. Date of Accident _________________________ Time ______________ AM/PM 3. Was the accident reported to your employer? ( ) Yes ( ) No Name of person reported to _______________________________________________ 4. Are you off work now? ( ) Yes ( ) No Date last worked _______________________ 5. Injured at: ______________________________ City ___________...