Are you writing on your own behalf or for someone else?
Self Someone Else

If you are writing for someone else, how are you related or connected to that person?

Please describe how you or the person for whom you are writing was injured. Include where and when the incident occurred and how many people were involved.

What injuries were sustained?

Have you received any medical care yet? (See your family physician)
Yes No

Did the accident occur at work?
Yes No

How do you prefer to be contacted?
Telephone E-mail

When is the best time to reach you?