“YOU DON’T PAY UNLESS WE WIN”

201-656-8500

White Finger Intake

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?


Yes

No

Do your hands, wrists or forearms ache?


Yes

No

Have you got problems with your hands in the cold?


Yes

No

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


Yes

No

Do your hands tingle and go numb?


Yes

No

What makes your hands tingle and go numb?

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


Yes

No

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

Are you covered by health insurance?


Yes

No

Do you or have you used the following tools?


Fein Knife or Cut-Out Tool

Percussive tools e.g. riveting, caulking, fettling and swaging

Grinders including pedestal and hand-held grinders

Pneumatic drills and hammers, including percussive and rotary hammers


Chain saws and other garden machinery

Other Tools

Have you ever worked in the windshield replacement industry?


Yes

No

Date of workers’ compensation or disability claim filed for hands