Worker's Compensation Form

Using a form is helpful, but not required. You can always contact us or call us at 207-780-6700 or toll free at 800-425-6700.

Name *
Name
Phone
Phone
Address
Address
Date of Birth
Date of Birth
Date of Injury
Date of Injury
Date of HIre
Date of HIre
Did you work for more than one employer at the time of your injury?
Did you lose time from work because of your injury?
Are you currently receiving weekly compensation?
Has the workers' compensation carrier paid all of your medical bills?