Contact Us New Jersey Lawyers: Petro Cohen Petro Matarazzo Warrington Attorneys serving Southern and Central New Jersey

The Executive Plaza
2111 New Road, Suite 202
Northfield, NJ 08225

Toll Free:
(888) 675-7607

Telephone:
(609) 677-1700

Fax:
(609) 677-1790

211 N. Main Street
Suite 101
Cape May Court House, NJ 08210

Toll Free:
(888) 675-7607

Telephone:
(609) 729-1187

Beowulf Plaza
1814 E. Rt 70 - Suite 336
Cherry Hill NJ 08003

Toll Free:
(888) 675-7607

Telephone:
(856) 673-4181

Do I have a workers' compensation case? Answer all questions (if known)

*Name:
Address:
Home phone number:
Cell phone number:
*Email address:
Date of birth:(mm/dd/yy)
Date of injury:(mm/dd/yy)
Name of employer:
Address of workers' compensation insurance company:
Claim number (or TPA if known) of workers’ compensation insurance company:
How accident happened (be specific as to how the injury occurred, for example “I slipped on grease while making a delivery and fell directly onto my right knee cap, causing a fracture”) (if applicable, describe the type occupational exposure or repetitive stress causing injury);
Has your claim been accepted by the workers’ compensation carrier?
Have you received authorized medical treatment from the workers' compensation insurance carrier or TPA?
If yes, provide the name and address of your main authorized treating physician.
What parts of your body do you claim were injured? (Use diagnosis where appropriate. For example, “head trauma/concussion, herniated L5-S1 unoperated, fractured right arm, etc.):
Best time to schedule an appointment:
How you are most easily contacted: