Case Evaluation Name* First Last Email* Phone*Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code What was the date of your accident?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Who is your accident employer?*What parts of your body did you injure?* Neck Foot Hand/Wrist Head Shoulder Psychological Knee Back Exposure To Chemicals OtherDid you receive medical attention?*YesNoHas the WSIB paid any benefits?*YesNoAre you currently working?*YesNoAre you currently receiving… WSIB Benefits Sickness & Accident CPP Disability Have you received any retraining from the WSIB?*YesNoIf so, what program?Do you currently have or had representation?*YesNoIf so, whom?Tell us about your WSIB problem in 100 words or less:*Submission of this form is not a retainer or agreement to represent you.NameThis field is for validation purposes and should be left unchanged.