Pennsylvania Workers Compensation Lawyers: Injury Disability Benefits, Medical Expenses, Workplace Hazards: PA Attorneys

1-800-318-LAW1 | Pennsylvania Law Offices: Scranton / Stroudsburg / Carbondale / Plains / Hazleton / Hamlin / Harrisburg

Pennsylvania Personal Injury Lawyers - Truck Injuries, Auto Accidents, Personal Injury, Workers Compensation - PA Attorneys

FREE WORKERS COMPENSATION CLAIM EVALUATION

Have you been injured on the job? Do you need medical treatment? Are you disabled as a result of the work injury? You may be eligible for medical treatment and weekly disability payments. Please complete the following questionnaire and submit it for an evaluation of your claim. There is no charge for the evaluation.

* Items are required.

CONTACT INFORMATION

First Name:* Last Name:*

*E-mail Address:

Home Phone:
- -

Cell Phone: - -

Work Phone: - - ext.

Street Address:

Address #2:

City:

State/Zip: /

What is the best way to reach you?
Please provide the best place, time and method for contacting you.

EMPLOYMENT / INJURY INFORMATION

Employer's Name:

Employer's Address:

Job Title:

Number of Years Employed:

Date of Injury:

Did injury occur in Pennsylvania:

Yes: No:

Did the injury occur on your employer's premises?
Yes: No:

Please briefly explain the incident that caused your injury:

Please describe your injuries?

Do you believe that any of your injuries are permanent?
Yes: No:

Do you have a permanent visible scar on your face, head or neck? Yes: No:

Are you a federal employee?
Yes: No:

Has a claim been accepted?
Yes: No:

If yes, has the insurance carrier filed a petition to modify, suspend or termination your claim?
Yes: No:

If No, have you received a notice of denial?
Yes: No:

When did you first receive medical treatment?

How did you hear about us?

About Workers Compensation Knowing Your Rights Workers Compensation FAQs Free Online Claim Evaluation Pennsylvania Workers Compensation News Labor Organizations Forklift Injuries Legal Associations Labor Statistics U.S. Government Departments & Agencies Bureau of Workers Compensation Information Workers Compensation Statistics Workers Compensation
District Offices Online Resources

Robert W. Munley Marion Munley Matthew A. Cartwright J. Christopher Munley Daniel W. Munley Robert W. Munley, III Julia K. Munley Caroline Munley View All Attorneys

Occupational Safety and Health Administration (OSHA) Pennsylvania Department of Labor and Industry Pennsylvania Workers Compensation Journal Pennsylvania Workers Compensation Law Scranton Wilkes-Barre Workers Compensation

Experienced Attorneys handling Tractor Trailer Accidents, Personal Injury Claims, Medical Malpractice, Workers Compensation, Car Accidents (PA Accidents 2006 / 2007),
Wrongful Death, Mesothelioma, and other injury lawsuits.
Scranton, Wilkes-Barre,Allentown, Bethlehem, Easton, Philadelphia, Archbald, Carbondale, Stroudsburg, Hazleton, Harrisburg - Pennsylvania, PA

Truck Accident Information: Alabama, California, Connecticut, Delaware, Florida, Georgia, Kentucky, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, West Virginia

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Representation in jurisdictions where our attorneys are not already licensed is performed in conjunction with local
counsel / lawyers - at no additional legal fees to our clients - and with permission of the court.