We handle dock and offshore injuries, and civilian work injuries that occur at federal installations which are covered by the Act. Please give us some information about your accident.
Longshore and Harbor Workers Act Questionnaire
Date of your accident? Location of your accident: City State Waters How did your accident happen? Employer’s Name City Insurance Co Are you receiving LHCA benefits at this time? Yes No What were your injuries? Who is your main doctor? Did a third party or someone other than your employer or fellow employees cause the accident? Please explain: Please explain any other facts you think would help us in evaluating your case: How were you referred to us? TV Yellow Page White Pages Friend Lawyer or Doctor Other Saw Victor Makris speak in a seminar If a person referred you to us please state their name:
Date of your accident?
Location of your accident: City State Waters
How did your accident happen?
Employer’s Name City Insurance Co
Are you receiving LHCA benefits at this time? Yes No What were your injuries?
Who is your main doctor?
Did a third party or someone other than your employer or fellow employees cause the accident? Please explain:
Please explain any other facts you think would help us in evaluating your case:
How were you referred to us?
TV Yellow Page White Pages Friend Lawyer or Doctor Other Saw Victor Makris speak in a seminar
If a person referred you to us please state their name:
