---YesNo
---Elementary (6th)Middle school (8th)High school (12th)CollegeGraduate school
53 W. Jackson Chicago, IL 60604-3607 312-427-2611 phone 312-427-2644 fax
Home » Client section » Recently attempted to work
To notify us that you have recently attempted to work, please fill out the form below.
Your name:
Email address:
Phone number:
How many times have you attempted to work since filing your claim or since you last updated us?
Employer's name and address:
How long did you work for this employer?
When was your last day of work?
What was your starting salary?
What was your ending salary?
Average number of hours worked per week:
Job title and description:
Input code: