Case Evaluation Form

If you have been injured while working, please complete our online Case Evaluation Form below or call us at 519-971-7777 to arrange for your free initial consultation, and see how we can help you.

Or, if you would rather download this form and fill it out at your leisure, you may download it here: (Download PDF) If you are unable to open this file, please download Adobe Acrobat Reader here http://get.adobe.com/reader/

Your Name*:
Your Email*:
Primary Phone Number*:
Alternate Phone Number:
Date of Accident*:
Accident Employer*:
Job Title*:
When was your last day of work?*:
Hourly Wage*:
Average # of hours worked per week*:
Area of injury*:
(check all that apply)
Do you currently have representation?*:
If so, whom?:
Did you receive any WSIB benefits?*:
How much weekly?:
Are you currently receiving*:
(check all that apply)
Other benefits (please specify):
Have you protected your right to appeal WSIB’s decision in writing?*:
If so, on what date?:

If not, do so now.
Tell me about the current problem your are experiencing with WSIB in 100 words or less:

© Lomazzo Worker's Compensation Appeals
The use of this website does not establish a paralegal-client relationship.