Workers' Compensation Complaint Generator

Parties and Addresses

Claimant Full Name *

Claimant Address

Claimant County

Employer Legal Name *

Employer Entity Type

Employer Address

Employer County

Insurance Carrier Name

Insurance Carrier Address

Policy Number

Jurisdiction and Venue

State *

County or District

Jurisdiction Statute

Venue Statute

Venue Reason

Workers Comp Act Citation

Employment Information

Job Title *

Average Weekly Wage

Incident Details

Date of Injury *

Time of Injury

Location of Injury

Detailed Description of Work Being Done

Description of Incident *

Conditions at Time of Injury

Known Hazards or Prior Complaints

Injury Details

Primary Injury Type

Secondary Injury Type

Additional Injuries

Psychological Injuries (check all that apply)

Anxiety Depression PTSD Sleep disturbance Fear/phobias Cognitive impairment Other

Immediate Symptoms

Medical and Benefits

Treating Providers

Average Weekly Wage

Compensation Rate (per week)

Permanent Disability (%)

Medical treatment received (check all that apply)

Emergency room visit Hospital admission Surgery Physical therapy Chiropractic care Prescription medications X-rays/imaging Injections/pain management Other

Additional treatment details

Ongoing Treatment Needs

Benefits Status

Terminated As Of (if applicable)

Notice to Employer

Date Notice Given

Person Notified

Notice Method

Verification & Service

Verification State

Verification County

Service Date

Service Method

Employer Service Address

⚠️ Important Disclaimer

This is an experimental feature, and its products should not be assumed to be ready to file. These generated complaints are meant to serve as a starting point for your pro se litigation. These complaints are generated with AI, and AI can make mistakes. Be sure to check that the facts described here are correct.

🛠️ Workers' Compensation Complaint Generator