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The Frison Firm, LLC.
Promenade II,
Suite 1900
1230 Peachtree Street
Atlanta, Georgia 30309
Office: 404.942.4330

Workers' Compensation Questionnaire

NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent via the Internet.


How were you referred to this office?

Name:

Street Address:

City:

State:

Zip:

Work Phone:

Home Phone:

E-mail:

Employer Name:

Date Employment Began

Date Employment Ended

What is/was your job title?

Rate of pay

Hours worked per week

Employment Status

Date of injury

Time of injury

County of injury

Description of incident

Description of your injuries

Have you received Worker's Compensation Benefits related to this claim?

Yes No

List any other attorney you previously hire to work on your claim

Please give the names, addresses and phone numbers of all medical providers:


THE FRISON FIRM represents clients throughout Georgia, including those in Downtown and Midtown Atlanta, Decatur, Alpharetta, Duluth, East Point, Lilburn, Stone Mountain, Lithonia, Covington, Clarkston, Peachtree City, Marietta, Conyers, Dallas, Savannah, Brunswick, Smyrna, Jonesboro, Lawrenceville, Sandy Springs, Buckhead, Gainsville, Athens, Austell, Carrollton, Macon, McDonough, Newnan, Norcross, Riverdale, Rockmart, Roswell, Stockbridge, Villa Rica and all cities within Fulton County, Dekalb County, Cobb County, Rockdale County, Gwinnett County, Bibb County, Whitfield County, Clarke County, Richmond County, Chatham County, Muscogee County, Floyd County, Houston County, Dougherty County, Clayton County, Carroll County, Henry County and Lowndes County.