Case Evaluation | Suzanne M. Dajczak

Name*

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Email*

Phone*

Address

Street Address Address Line 2 City Province Postal Code

What was the date of your accident?*

Who is your accident employer?*

What parts of your body did you injure?*

Other

Did you receive medical attention?*

Has the WSIB paid any benefits?*

Are you currently working?*

Are you currently receiving…

Have you received any retraining from the WSIB?*

If so, what program?

Do you currently have or had representation?*

If so, whom?

Tell us about your WSIB problem in 100 words or less:*

Submission of this form is not a retainer or agreement to represent you.

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