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Name: Fillable Online Accident/injury Questionnaire - United Food & Commercial Workers Local 655 Fax Email Print - pdfFiller
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This document is an accident/injury questionnaire sent by the Welfare Fund Benefits Office of United Food & Commercial Workers Local 655. It is used to gather additional information regarding a claim for an injury or accident to facilitate processing. The questionnaire includes questions about the member and patient details, accident specifics, and a certification of the information provided.

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How to fill out accidentinjury questionnaire

01

Read the instructions carefully.

02

Provide your personal information (name, address, contact details).

03

Describe the accident or injury in detail (date, time, location).

04

List any injuries sustained as a result of the accident.

05

Include details about witnesses, if any.

06

Provide information about any medical treatment received.

07

Attach any relevant documents or evidence (photos, reports).

08

Review your answers for accuracy.

09

Submit the questionnaire to the appropriate party.

Who needs accidentinjury questionnaire?

01

Individuals who have experienced an accident or injury.

02

Insurance companies assessing claims.

03

Legal professionals evaluating a case.

04

Employers conducting workplace injury assessments.

05

Healthcare providers documenting patient history.

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What is accidentinjury questionnaire?

The accident injury questionnaire is a document used to collect detailed information related to an individual's injuries and circumstances surrounding an accident for insurance or legal purposes.

Who is required to file accidentinjury questionnaire?

Individuals who have been involved in an accident and are seeking compensation for injuries or damages typically are required to file an accident injury questionnaire.

How to fill out accidentinjury questionnaire?

To fill out the accident injury questionnaire, you should provide personal information, details about the accident, descriptions of injuries, and any medical treatment received. Answer all questions accurately and thoroughly.

What is the purpose of accidentinjury questionnaire?

The purpose of the accident injury questionnaire is to gather comprehensive information that helps assess claims for injuries or damages related to an accident.

What information must be reported on accidentinjury questionnaire?

The information that must be reported includes personal identification details, accident circumstances, descriptions of injuries, treatment history, and any relevant witness information.

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