Questionnaire A

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Questionnaire A : Years Of Accident Up To And Including 1989.

Name:____________________________

Phone #:____________________________

Address:

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Date of Birth:______________________

Date of Accident:___________________

W. S. I. B. Claim Number(s):

Injuries from the work accident:

Any other health problems (not from the work acident)?:

Previous Representation:

No: ________________

Yes: _______________ by whom? _____________________________________________

Entitlement Related Questions

1. What was your job at the time of accident? (describe)

2. What were your earnings at the time of accident, hourly, weekly, and yearly?

3. How long were you employed with the employer at the time of accident, weeks, months, years?

4. Did the Board allow initial entitlement of your claim? If not explain why?

5. What was your weekly, and monthly Worker's Compensation Rate paid while on benefits?

6. How long were you paid compensation benefits from date of accident? example: 1 week, or
7 months, or 10 years?

7. (A) Did you receive any retraining from the Board? If so, what type of retraining, when and
where? Example: returned to school for truck driving, civil engineer technician Etc., from 1982
till 1985.

7. (B) If you were not retrained, then provide a description of past vocational rehabilitation
services that you were involved in with the Board. Example: six months job search for gas bar
attendant. Etc.

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8. Did you receive a pension from the Board? If so from when (what year). What is the percentage
of your pension? Example: 10%. What is the monthly payment of the pension? Example: $200
monthly.

9. Are you presently receiving a Board Supplement to your pension? If so, how much monthly?

10. Describe your employment history if any, after the accident; and the yearly earnings of your
employment history. Example: Employed from 1981 till 1982 in a fabric factory, earning $8.00
hourly being $16,000 yearly. Etc...

11. Your present employment and earnings ststus? Or if you are not presently working than please
outline your status (source of income). Example: Canada pension, Disability insurance, Social
assistance, Employment insurance, retired, Etc...

12. Throughout your Workers' Compensation History, did you experience any personal working
relation problems with either the claims adjudicator and/or the vocational rehabilitation case worker?
If so explain:

13. Any other information that you would like us to know?

14. Any questions that you may have?

15. The best days and times to telephone you to discuss our questionnaire reviews are: Thank You.

Date Completed: ________________