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Basic identifying information. This includes full name, age, date of birth, Social Security number, drivers license number, address, phone numbers, former names, and names of previous spouses. |
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Family information. This includes marital status and identity of spouse or partner. Obtain the names, ages, dates of birth of dependents. |
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Employment information. This includes occupation, length of service, hours worked, salary and other compensation, including commissions, bonuses, stock options, meals, lodging, tips, and any other compensation.. Determine the normal location of employment. |
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Employment terms. Obtain copies of any employment contracts. Inquire about any unwritten employment agreements. |
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Prior employment. Get record of job history including contact information for previous employers. Previous claims. Cover in detail. |
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Place and hours of employment. Any deviation involved if accident away from employer's premises? |
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Occurrence. Date, time, and place of occurrence. If the occurrence was an accident, ask what the claimant was doing at the time of the time. Obtain the details of the occurrence, that is, when, where, what and why. Get identity of witnesses. If the occurrence was a continuing trauma get description of exact physical activities causing the injury. |
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Injury. Description of the injury and names of medical treatment providers. Get description of current symptoms. |
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Disability. If the claimant is not working, how long off work. Get description of current activities. Determine if injury affects non-employment activities. |
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