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Workers’ Compensation Intake Questionnaire

Please tell us about your on-the-job injury so we can see how we may be able to help. Louisiana comp deadlines can run from the accident and from the last benefit payment — so please answer as completely as you can, especially the dates. There are no wrong answers, and you can skip anything you are not sure about.

985-612-7220 | stephen@aertkerlegal.com | www.aertkerlegal.com | 229 N. Vermont St., Covington, LA 70433
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PLEASE READ FIRST. Submitting this questionnaire does not create an attorney-client relationship and does not by itself make you a client or prospective client of the firm. No representation begins until the firm has checked for conflicts of interest and you and the firm have signed a written engagement agreement. Do NOT include your full Social Security number anywhere on this form. We will collect it securely later if the firm takes your case. Please name any employers you worked for in the last 5 years and any lawyer or advocate who has represented you on this claim, so the firm can check for conflicts of interest. Information you submit is handled confidentially consistent with Louisiana Rule of Professional Conduct 1.18.
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Contact Information
Please tell us who you are and the best way to reach you.
2
Your Employer & Their Insurance Company
This also lets us run the conflict check every law firm must complete before discussing a matter in depth.
If an adjuster is asking for one and you have not given it yet, it is worth talking to us first. You must always be truthful with the insurer — but recorded statements shape a claim early, and careful answers protect you.
3
The Accident
Dates matter more in workers’ comp than almost anywhere else in the law.
Your benefit rate, your deadlines, and the rules that apply all key off this date.
4
Your Injuries
Check everything that applies — including parts that “only bother you a little” right now.
Answer honestly — a prior injury does not defeat a comp claim, but insurers comb medical histories, and accuracy here is one of the strongest protections your claim has.
5
Medical Treatment
Louisiana gives you the right to choose your own treating physician — one in every specialty. Who picked yours matters.
Being steered to “the company doctor” is not something you have to accept — and if the insurer is refusing to authorize the doctor you chose, the law provides a fast-track fix.
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Your Job & Pay
Every benefit in your case flows from your average weekly wage — and underpaid wage calculations are one of the most common ways workers get shorted.
Overtime and second jobs can raise your average weekly wage — and your weekly check.
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Benefit Checks & Payments
The payment history is where deadlines hide and where penalties are found. Dates here are gold — even approximate ones.
Important: some comp deadlines run from the last payment, not the accident.
Louisiana requires formal notice before benefits are cut off — keep the letter and the envelope.
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Work Status Today
Where things stand right now.
If you earn meaningfully less than before the injury, wage-loss benefits may apply.
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Documents
If you have them handy, these help enormously: the accident report, pay stubs (ideally several months’ worth — they drive the wage calculation), medical records or discharge papers, every letter from the insurer (especially anything sent certified mail — keep the envelopes), and photos. Total attachments up to about 7MB; anything larger, just bring it to the consultation.
A driver, a manufacturer, another company’s crew — a separate lawsuit may exist alongside the comp claim, on its own (different) deadline.
Comp and SSDI interact — and the wording of a comp settlement can protect (or quietly shrink) the Social Security check.
Retaliation for asserting a comp claim can violate Louisiana law — and carries its own short deadline. Tell us.
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Documents
Letters from Social Security tell us your deadlines, so they are the most helpful documents you can share.

If you can, attach up to three documents: (1) the most recent denial or notice letter from Social Security, (2) any award or overpayment letter, and (3) a list of your medications or doctors. PDF, Word, or image. Photos of letters taken with your phone are fine. You may bring or email additional documents to your consultation.

Up to ~7 MB total across all files. For larger or highly sensitive files, please email them separately or bring them to your appointment. Please do not upload anything showing your full Social Security number.

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Anything Else & Submission
You're almost done. Add anything we didn't ask about, then submit.

For questions about this form or to reach our office, contact 985-612-7220 or stephen@aertkerlegal.com.

Learn about our Workers’ Compensation practice

This questionnaire is confidential. Communications from prospective clients are protected under Louisiana Rule of Professional Conduct 1.18. Stephen C. Aertker, Jr. is licensed in Louisiana and Mississippi.