Client Forms

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Additional Client Forms

For your convenience, we have posted some of our forms on the website. Click the link below to open, download, and print the needed document.

PERSONAL INJURY FORMS

• Authorization to Release Medical Information (HIPAA)
• Application for No-Fault Benefits (PIP) 3 pages
• Wage and Salary Verification (for earnings before accident)
• Mileage Claim Reimbursement
• MEDICARE Information Authorization

WORKERS’ COMPENSATION FORMS

• Attestation Form for Petition for Benefits
• Authorization to Release Medical Information (HIPAA)
• Wage Statement for Pre-Accident Earnings
• Mileage Claim Reimbursement
• Statement of Charges for Drugs and Medical Supplies Reimbursement
• Social Security Consent for Release of Information

DEFENSE BASE ACT AND LONGSHORE & HARBOR WORKERS’ COMPENSATION ACT

• Authorization to Release Medical Information
• Report of Earnings LS-200
• Notice of Employee’s Injury or Death LS-201
• Employer’s First Report of Injury or Occupational Illness LS-202
• Employee’s Claim for Compensation LS-203
• Claim for Death Benefits LS-262

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