UPDATE INFORMATION REGARDING PENDING CLAIM
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
Have you returned to work since we last spoke? Yes No
Date Returned
Were you paid worker's compensation benefits for all periods lost from work? Yes No
Any other information of which you would like to advise us:
Have you seen any other doctors or received any additional testing or other procedures?
1. I Was Treated By:
Name
Referred By
Address
City
State
Zip Code
DATES OF TREATMENT
Beginning:
Ending:
Course of treatment (please include any and all testing):
2. I Was Then Treated By: (if applicable)
Name
Referred By
Address
City
State
Zip Code
DATES OF TREATMENT
Beginning:
Ending:
Course of treatment (please include any and all testing):
3. I Was Then Treated By: (if applicable)
Name
Referred By
Address
City
State
Zip Code
DATES OF TREATMENT
Beginning:
Ending:
Course of treatment (please include any and all testing):
Please verify that the above is true and accurate, and then press the button below to submit the information to us.