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General Information
Name
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Street Address
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How did you hear about us?
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Other Lawyer
Internet/Google
Existing client of firm
Former client of firm
What is the name of the other lawyer?
We would like to send a thank you.
What is the name of the existing client?
We would like to send a thank you.
What is the name of the former client?
We would like to send a thank you.
Is this a WSIB or CPP Disability issue?
(Required)
WSIB
CPP
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WSIB
If WSIB issue, have you already filed a claim?
(Required)
Yes
No
What was the date of your injury?
(Required)
MM slash DD slash YYYY
What was your injury? (tick all that apply)
(Required)
Neck
Shoulder
Back
Knee
Hand/Wrist/Elbows
Leg/Foot
Psychological
Chronic Illness e.g. cancer, COPD
Exposure to chemicals or other hazards
Other
Please specify the other injury
What is your job/position?
What is the name of your employer?
(Required)
Full-time or part-time?
Full-time
Part-time
Are you paid hourly or salary?
(Required)
Hourly
Salary
How many hours per week do you normally work?
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What is your normal hourly rate of pay?
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Do you get paid overtime?
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No
Is overtime a regular part of your earnings?
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Yes
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How much overtime do you usually earn each week?
What is your annual salary?
Do you receive any bonus payments?
(Required)
Yes
No
What is your usual or average bonus payment?
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Are you currently working?
(Required)
Yes
No
What date did you stop working on?
MM slash DD slash YYYY
Have you been back to work since that date?
(Required)
Yes
No
Was it with your original employer or a different employer?
Original
Different
What work were you doing when you went back to work?
Has WSIB paid you benefits for all the time you were out of work because of this injury
(Required)
Yes
No
Has WSIB paid you for any of the time you were out of work because of your injury?
(Required)
Yes
No
Were you offered modified work by your employer following your injury?
(Required)
Yes
No
Did you try it?
(Required)
Yes
No
Why not?
Is the WSIB telling you that you have to go back to work?
(Required)
Yes
No
Is your doctor/treating specialist telling you that you’re not fit to go back to work yet?
Yes
No
Have you received any other benefits or payments from WSIB, such as a Non-Economic Loss Award?
(Required)
Yes
No
How much was the award for?
Have you received any other benefits since your injury? (tick all that apply)
(Required)
Employment Insurance Sickness Benefit
Sickness & Accident Benefits
CPP Disability Benefits
Ontario Disability Support Payments
Short Term Disability Benefit (Employer Scheme)
Long term Disability Benefit (Employer Scheme)
None
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CPP
What is the date of the decision denying you CPP Disability Benefits?
MM slash DD slash YYYY
What was the reason given for denial?
Insufficient CPP contributions
Not severe enough disability
Disability not prolonged
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