Your name, claim number, e-mail address (confidential information) will not be sold, shared, or dispensed. It may be used to verify authenticity of the data gathered.

1. Last Name: (Optional)

2. Claim #: (Optional)

3. Type of Injury / Disease: 

4. Occupation of Injury / Disease: 

5. Date of Incident: (Ex: 02/12/2005)

6. Date L&I received Claim: (Ex: 02/12/2005)

7. Was the Claim Allowed or Denied? 
Allowed
Denied


7a. On What Date? (Ex: 02/12/2005)

8. If the claim was denied did you protest or appeal? 
No
Yes
Not Applicable


8a. If the claim was allowed did your employer of injury protest or appeal? 
No
Yes
Not Applicable


9. Did your Dr. advise you to not return to work? 
No
Yes
Returned with Restricted Limitations


9a. Did your Employer of Injury keep you on Salary? 
Yes
No
Not Applicable


10. Length of time off work due to Dr.'s advice? (Ex: 4.5 day, wk, month, yr.)

11. Did you receive Time-Loss payments from the Dept. of L&I? 
Yes
No


12. Was time loss denied by a written order? 
Yes
No


12a. After the Dr. advised the Dept. you were off work, how long until the written 
Order of denial of Time-Loss? (Ex: 4.5 day, wk, month, yr.)

13. Have you attended an IME? 
No
Yes


13a. If more than one, how many? (For this Claim)

14. How many times has this claim been closed? 

14a. How many times has this claim been re-opened by protest or appeal? 

15. Length of time claim has awaited an order when under protest? 

16. Describe the disposition, personality of your Claim Managers: 
Caring
Polite
Unconcerned
Arrogant


17. Has the Dept. fulfilled their Motto (We Listen, We Care, We Respond)? 
Yes
No


18. Do you feel as though the Dept. of L&I knowingly made false statements or willfully 
misrepresented a material fact in any application for any payment under this title? 
No
Yes


19. Do you feel as though your employer of injury made false statements or willfully
misrepresented a material fact in any application for any payment under this title? 
No
Yes


Place your thoughts and concerns in this text box


The form will load into your e-mail when you click the image below.
Your e-mail will not be sold or exchanged with anyone.

"Send" to:
injuredXworker@earthXlink.net (copy & paste)
(remove the red X's from the e-mail address before sending.)