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Friday, 30 July 2010
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Bryan C. Ramos
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Contact Name
*
Contact number
*
E-mail address
*
Address
Date of Injury
*
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Company Name
Address of company
Hire Date
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Was claimant working for anyone else at the time of the injury
Yes
No
Claimant's job title and duties
Employer paid taxes on claimant's behalf
Yes
No
Don't know
List the body part(s) injured
*
Briefly, describe how the accident occured
*
Claimant has: (select all that apply by using the control key and clicking those that apply)
Missed time from work due to this injury.
Been terminated by the Employer.
Returned back to work.
Been a party to a lawsuit.
Been arrested.
Filed a workers' comp claim before.
Are you currently represented by an attorney?
*
Yes
No
Bryan C. Ramos,
2010 Georgia Rising Star
Bryan Camacho Ramos
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