EnglishFrenchGermanItalianPortugueseRussianSpanish
Accident Attorneys in NJ | NY | FL

White Finger Intake Form

Please fill out the information requested below and a representative will contact you.

Name

Address (City, State, Zip)

Email

Home Phone

Work Phone

Name and Address of Most Recent Employer

Job Title

Date Hire

Date Retire

Do your hands go white?
YesNo

Do your hands, wrists or forearms ache?
YesNo

Have you got problems with your hands in the cold?
YesNo

Do you have problems with your hands due to using vibrating power tools?
YesNo

Do your hands tingle and go numb?
YesNo

What makes your hands tingle and go numb?

Have you been diagnosed by a doctor with any hand problems?
YesNo

If yes, list name and address of doctor and date of diagnosis.

Are you covered by health insurance?
YesNo

Do you or have you used the following tools?
Fein Knife or Cut-Out ToolPercussive tools e.g. riveting, caulking, fettling and swagingGrinders including pedestal and hand-held grindersPneumatic drills and hammers, including percussive and rotary hammersChain saws and other garden machinery

Other Tools

Have you ever worked in the windshield replacement industry?
YesNo

Date of workers' compensation or disability claim filed for hands

To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.

Verification:

Jersey City (Main Office)

Bagolie Friedman Injury Lawyers
648 Newark Avenue
Jersey City, NJ 07306

201-656-8500
Toll Free: 866-333-3529 and
1-888-422-4654 (888-4-Bagolie)

info@bagoliefriedman.com

Other Locations

Clifton
157 Ackerman Avenue
Clifton, NJ 07011
Phone: (973) 546-5414

New York
377 Oak Street
Garden City, NY 11530
Fax: (954) 927-0337

Florida
3900 Hollywood Blvd.
Hollywood, FL 33021

Follow Us

Subcribe to Our Newsletter

Get the Bagolie Friedman NEWSLETTER-CLICK HERE