Free F242-067-000 inquiry for assessment of damages - Washington

Department of Labor and Industries Third Party Unit PO Box 44288 Olympia WA 98504-4288

INQUIRY FOR ASSESSMENT OF DAMAGES
Name of Claimant Claim Number Date of Injury

Your answers to these questions will be used to assist in evaluating your damages if a claim is made against the liable party.
1. State the name of each doctor, therapist and laboratory you have seen because of your injury. Do not include items paid by the Department of Labor and Industries.

2. Has treatment ended?

Yes

No

If yes, what was the last date you received treatment?

3. Did you use or wear any brace, appliance, bandage, traction, crutches, wheelchair, special bed, mattress or board, medical collar or other aids If yes, what type? because of your injury? Yes No 4. List and describe all medications taken for this injury. 5. Did you use any home treatments (such as heat lamp, electric pad, hot water bottle, hot bath or shower, massage, special exercises, etc.)? If yes, please describe the treatment and how often used. Yes No

6. Was there anything at work, home or elsewhere that you could not do or found difficult to do because of your injury? If yes, describe. Yes No

7. Did you lose any time from work because of your injury? If yes, give dates missed and wages lost; include sick leave or vacation used due to the injury. Yes No

8. List all expenses you have incurred due to this injury and not paid by the department. If possible, attach copies of bills and/or receipts.

9. Describe any lasting effects from this injury, i.e., a limp, scar, recurring pain.

10. Do you expect to incur further expenses or require further treatment due to this injury? If yes, explain. Yes No 11. Describe the pain you suffered from this injury; the severity, duration and part of body.

Date

Signature of Claimant

Use additional sheets if necessary
F242-067-000 inquiry for assessment of damages 3-07

RESET