Step 7 | Gaylord Claims

Personal Injury Case Builder Form

When you begin our personal injury intake process, you should be ready to tell us about your incident. Whether it was a car accident, slip and fall or dog bite, we want to hear the all the details and specifics. Be descriptive but keep the information relevant. This will help us to better assess your claim.

Name(Required)

First Last

Email(Required)

Step 7 - Specific Wage Loss Information and Duties Under Duress Information

When you suffer injuries and cannot return to work immediately, a personal injury claim of lost wages can be filed. A lost wages claim seeks to hold the at-fault party in an personal injury matter responsible for reimbursement of the victim's missed paychecks while healing from the incident.

Are you currently employed?

Yes

Specific Employer Information

Employer’s Name:

Employer’s Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer’s Phone

Dates of Employment: From Date

MM slash DD slash YYYY

Dates of Employment: To Date

MM slash DD slash YYYY

Wage or salary as of date of collision:

Wage

Per Week

Per Hour

Per Day

Per Month

Tips or other supplemental income:

Tips

Per Week

Per Hour

Per Day

Per Month

Usual number of days worked per week:

Usual number of hours worked per day:

Date disability started:

MM slash DD slash YYYY

Date returned to work:

MM slash DD slash YYYY

Were you paid during your absence?

Personal time

Vacation time

Other

Still working? Why have you continued to work?

I would lose my job if I took time off.

I couldn’t support my family otherwise.

I don’t believe in taking time off even when I am injured or in pain.

My business would fail if I did not work.

I cannot take time off because I care for my own children.

Other

Please Describe( If Other Selected )

Are you operating under work restrictions since your injury?

Yes

Please Describe

Has your employer temporarily accommodated your injury by reducing work duties, travel, or responsibilities?

Yes

Please Describe

Are you working fewer hours because of your injury?

Yes

Please Describe

Do you have to get up and move around frequently, or have you changed your workstation?

Yes

Please Describe

Have you lost your job because you can no longer perform the necessary work duties?

Yes

Please Describe

Have you lost your opportunity for overtime work and the additional compensation that comes with it?

Yes

Please Describe

Duties Under Duress

My doctors have instructed me that my inability to perform my normal pre-accident work activities without pain is a permanent condition.

My problems in performing my normal work activities is ongoing, but my doctors have not instructed me that the conditions is permanent.

I experienced problems doing my normal work activities for _____ weeks.

I have experienced the following changes in my ability to perform at work:

Mobility/Stability Problems

Climbing

Kneeling

Lifting

Walking for Long Periods

Dexterity Problems

Finger Movements

Wrist Movements

Problems with Fatigue

Postural Difficulties

Bending

Sitting for Long Periods

Standing for Long Periods

Stooping

Problems with Anxiety/Depression

Problems with Vertigo or Spinning Sensations

Dizziness

Giddiness

Sensation of Irregular Motion

Sensation of Whirling Motion

Problems with Tinnitus or Ringing in the Ears

Problems with Reduced Concentration

Can’t Concentrate

Can’t Think Properly

Making Mistakes

Pain

Where?

HOUSEHOLD

Painting the Outside of the House

Landscaping

Mowing the Grass

Trimming the Bushes/Trees

Washing Windows

Gardening

Taking Out the Trash

Washing the Cars

Maintaining the Cars

Maintaining Yard Equipment

Doing Other External House Work

I have experienced problems with the following activities outside my home:

Specify:

DOMESTIC DUTIES

I have experienced pain while performing the following activities inside my home, but have done them anyway:

Laundry

Dishwashing

Vacuuming

Washing Windows

Cleaning

Preparing Meals

Due to my injuries, I have brought in the following assistance:

Paid Housekeeper

Unpaid Assistance

None

My family status would best be described as:

Single

Single Parent at Home

Spouse Only

Spouse and Children at Home

I have the following number of children:

The number of my children in the following age category is:

Number of children 0 to 5 years:

Number of children 5-11 years:

Number of children older than 11:

Domestic Assistance

I did receive domestic assistance

I did not receive domestic assistance

Duration of Symptoms

My doctors have instructed me that my inability to perform my normal pre-accident domestic activities without pain is a permanent condition.

My problems in performing my normal domestic activities is ongoing, but my doctors have not instructed me that the conditions is permanent.

I have experienced problems doing my normal domestic activities for _____ weeks.

STUDIES/EDUCATIONAL DUTIES

As a student I have experienced problems with one of the following activities since the collision:

Carrying Books

Sitting in Classes

Looking Down to Read Laptop or Textbooks

Other:

If Other Please Describe

I have also experienced the following changes in my ability to perform at school as a result of injuries sustained in my accident:

Mobility/Stability Problems

Climbing

Kneeling

Lifting

Walking for Long Periods

Dexterity Problems

Finger Movements

Wrist Movements

Problems with Fatigue

Postural Difficulties

Bending

Sitting for Long Periods

Standing for Long Periods

Stooping

Problems with Anxiety/Depression

Problems with Vertigo or Spinning Sensations

Dizziness

Giddiness

Sensation of Irregular Motion

Sensation of Whirling Motion

Problems with Tinnitus or Ringing in the Ears

Problems with Reduced Concentration

Can’t Concentrate

Can’t Think Properly

Making Mistakes

Pain: Where?

At the time of this collision, my education would best be described as:

High School

Apprenticeship Studies

Technical College

University

Correspondence Course

My attendance before the collision is best described as:

Full Time

Part Time

Duration of Symptoms

My doctors have instructed me that my inability to perform my normal pre-accident studies/educational activities activities without pain is a permanent condition.

My problems in performing my normal studies/educational activities activities is ongoing, but my doctors have not instructed me that the conditions is permanent.

I have experienced problems doing my normal studies/educational activities for _____ weeks