Workers Compensation

Step 1 of 15

Email(Required)

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Were you coerced, incentivized or mandated a vaccine?(Required)

Yes

Who coerced, incentivized or mandated it ?

Were you given a date in which if you didn't comply you would be put on administrative leave, have to resign, or be fired?

Yes

Maybe

If you were put on administrative leave, have to resign, or be fired, what date was your last day of work?

DD slash MM slash YYYY

If you were coerced, incentivized or mandated a vaccine please upload additional documents, emails, flyers, photos or audio files of messages left on your voice mail if applicable.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, eml, mpeg-4, mp3, mp4, wav, Max. file size: 128 MB.

If yes, you were coerced, incentivized or mandated a vaccine and believe you were injured, please share which of the following conditions you have been diagnosed with:

Myocarditis/Pericarditis

Postural Tachycardia Syndrome (POTS)

Coagulopathy

Acute Myocardial infraction

Anaphylaxis

Covid-19 disease

Gullain-Barre syndrome

Kawasaki disease

Multisystem inflammatory syndrome in children

Multisystem inflammatory syndrome in adults

Nacrolepsy / Cataplexy

Pregnancy and Prescribed Conditions

Seizures / Convulsions

Stroke

Transverse Myelitis

Other:

Have you already started the claims process or already have a Workers Compensation attorney on the case?

Yes

Maybe

Have you reported the the suspected injury to your employer?

Yes

Maybe

What date did you receive your last shot?

DD slash MM slash YYYY

What date did you report it?

DD slash MM slash YYYY

Have you filed a claim form alleging work related injury?

Yes

Have you signed on with a Workers Compensation attorney to represent you?

Yes

Other

If you have signed up with a Workers Compensation attorney, can you please provide their name and phone# so we can possible send him other cases after we interview and vet them.

Enter your contact information

Name

First Last

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Referred By?

Referred By? : Other

Were you given informed consent, verbally, or in writing?

Yes

If yes, do you have a printed copy of what you were presented that day?

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docs, docx, Max. file size: 128 MB.

Enter your contact information

Referred By?

Warp Speed Legal

Questions?

My Legal Issue

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