Questionnaire C

title5.jpg (7136 bytes) title4.jpg (6636 bytes)
Questionnaire C : Years Of Accident from January 1st, 1998 to Date.

Name:____________________________

Phone #:____________________________

Address:

________________________________________________________________
________________________________________________________________
________________________________________________________________

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. What did you earn as income (income tax returns) for the past 5 years before the work accident?
What type of employment were you invovled in?

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

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

6. What was your Short Term weekly (STM), and Long Term weekly (LTM) Workers'
Compensation Rate paid while on benefits?

7. How long were you paid compensation benefits from date of accident? example: 1 week, or
7 months, or 2 years?

8. (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 1998
till 2000.

8. (B) If you were not retrained, then provide a description of past Labor Marker Re-entry (LMR)
services that you were involved in with the Board. Example: six months job search for gas bar
attendant. Etc.

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

9. Did you receive a Non Economic Loss award from the Board? If so, what year? What is the
percentage of your NEL? Example: 10%. Was it paid in a lump sum or monthly payments?

10. Did you receive a Loss of Earnings award (LOE) from the Board? If so what year and have the
LOE reviews occurred? What is the monthly amount of your loss of earnings award, if any?

11. From your understanding, what was the Loss of Earnings (LOE) award based on?
Example: Projected wages of Business administration, Graphic artist, Parking lot attendant.

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

13. Describe your employment history if any, after the accident; and the yearly earnings of your
employment history. Example: Employed from 1998 till 1999 in a fabric factory, earning
$8.00 hourly being $16,000 yearly. Etc.

14. Your present employment and earnings status? 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...

15. 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:

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

17. Any questions that you may have?

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

Date Completed: ________________