Ability Management Solutions - Request for Services Form - ADVOCATE FOR INJURED WORKERS OF ALBERTA

Request for Services Form

Personal Information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Do You Currently Have an Advocate? *

Yes No

Claim Information

Services Required? *

What issue are you currently needing an advocate to assist with? *

Claim Number(s) *

Date of Accident *

Employment Status? *

What Province Were You Injured? *

Status of Claim *

Accepted Denied Pending Decision Not Applicable

Are You Currently in Receipt of Benefits? *

Yes No

What is your pre-accident annual gross salary and position? *

If your current earnings are estimated, what position did WCB deem you fit to work in? *

What is your monthly wage benefit being paid by WCB and the amount? *

Are you receiving any other allowances or income from WCB other than our wage loss benefits? If so, please list them. *

List injuries accepted by the WCB *

List Injuries Denied by WCB *

List approximate dates of surgeries *

What are your current work restrictions? *

Level of Appeal? *

Please Provide Any Additional Information Regarding Your Claim *

Additional Information

How Did You Hear About Us? *

Other? *

Submit

Request for Services Form

Request for Services Form

Claim Information

Additional Information

I would love to hear from you and discuss how my experience can support you!

Hours

Telephone

Email

​Request for Services Form

Request for Services Form

Claim Information

Additional Information

I would love to hear from you and discuss how my experience can support you!

Hours

Telephone

Email

Request for Services Form