Worker's Compensation

Workers’ compensation and often abbreviated as Workers’ Comp, is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment.

INJURED AT WORK?

You deserve compensation

We help the injured protect their rights and get compensated
for their claims

INJURED AT WORK?

You deserve compensation

We help the injured protect their rights and get compensated
for their claims

PERSONAL INJURY INTAKE FORM

Please fill out the form below and we will respond in less than 24 hours

    I. Client Information


    Address (required)
    Cell (required) Home Phone
    Your Email (required)

    II. Accident Information

    Date of Accident (required)
    Type of Accident AutoSlip & Fall
    Location (required)
    Description of Accident (required)
    Police Notified? YesNo Report Made? YesNo By Whom Were any arrests made:YesNo Name of Defendant: Address

    III. Medical Information


    1. Where Were You Hospitalized? When? Doctor?
    2. Where Were You Hospitalized? When? Doctor?

    IV . Insurance

    Auto Coverage Company Limit Full or Limited Tort Underinsured / Uninsured Motorist Coverage Medical Insurance Company
    Palm Beach Office 721 US Highway 1 Unit #115 North Palm Beach, FL 33408

    Local Phone: 561-543-9226 Nationwide: 1-800-241-1559

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    DISCLAIMER: The information on this website is for general information purposes only. Nothing on this site should be taken as legal advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute, an attorney-client relationship. No content on this site may be reused in any fashion without written permission from The Gaines Firm