FACT SHEET OF CORNFIELD AND FELDMAN
PLEASE NOTE: WE CANNOT FILE YOUR CLAIM WITHOUT THIS INFORMATION
The following is a three-step form that will collect information about your claim. Please answer all questions truthfully and as accurately as possible. This information will be forwarded onto Cornfield & Feldman for review. Please remember, we can not file your claim until we have reviewed this information and have received back from you additional documents which will be forwarded to you.

If you have any questions, please call (800) 621-3821 or (312) 236-7800.
PERSONAL INFORMATION
Your Name
Address
City
State
Zip Code
Phone Number
Email Address
Social Security No.
Gender Male Female
Date Of Birth
Marital Status
CHILDREN UNDER 18 AT TIME OF ACCIDENT
Name Age Gender
Male Female
Male Female
Male Female
Male Female
Male Female
Name of Nearest Friend or Relative
Phone Number of Nearest Friend of Relative
Relationship
EMPLOYMENT INFORMATION
Employer
Address
City
State
Zip Code
How long have you worked there? years and months
Job Title
Gross Salary (before taxes) $
How were you paid? Weekly Bi-Monthly Monthly On Commission
Overtime Wages $
Piecework / Bonus Incentives $
Describe your duties including names of any machinery used, light or heavy work, tools or appliances used:
Please verify that the above is true and accurate, and then press the button below to continue on to the second part of the form.