Book Your Appointment Today | PWR Retirement Group

X/Twitter

This field is for validation purposes and should be left unchanged.

First Name*

Last Name*

Phone Number*

Email Address*

Mailing Address

Street Address Street Address Line 2 City State / Province ZIP / Postal Code

FEDERAL EMPLOYMENT INFORMATION

Preferred Method of Contact

Agency*

Duty Station / Work Location

Position Title

INJURY OR ILLNESS INFORMATION

Employment Status

Supervisor Name

Years of Federal Service

Please enter a number less than or equal to 50.

Type of Case

Date of Injury or Date Symptoms Began*

Location where injury occurred

Describe how the injury or illness occurred

OWCP CLAIM INFORMATION

What job duty were you performing when the injury occurred?

Did anyone witness the incident?

Yes

No

If yes, Witness Names

Did you report the injury to your supervisor?

Yes

No

Date the injury was reported

MEDICAL INFORMATION

Have you filed an OWCP claim?

Yes

No

Not Sure

Claim Number

Which form was filed?

Date the claim was filed

Current claim status

Have you received a written OWCP decision?

Yes

No

Primary diagnosis

Body parts affected

COMPENSATION STATUS

Treating physician name

Physician specialty

Has your doctor connected the condition to your work duties?

Yes

No

Not Sure

CURRENT PROBLEM

List treatments received such as: Physical therapy, Surgery, Medication, Injections, Other

WORK STATUS AND LIGHT DUTY

Current work status

Upload OWCP letters or decisions

Drop files here or

Max. file size: 6 GB, Max. files: 100.

Upload medical reports or supporting medical documents

Drop files here or

Max. file size: 100 MB.

Were you offered light duty or modified duty?

Yes

No

Did you accept or decline the assignment?

Last day you worked full duty

COMPENSATION STATUS

Did you receive Continuation of Pay (COP)?

Yes

No

Not Sure

Are you currently receiving OWCP wage-loss compensation?

Yes

No

Have OWCP payments ever been delayed, reduced, or stopped?

Yes

No

Explain the issue

CURRENT PROBLEM

What issue are you currently experiencing with your OWCP case?

Examples: Claim denial; Delayed payments; Medical evidence dispute; Light duty issues; Return-to-work problems; OWCP requesting additional medical evidence

Provide a description of the problem

TIMELINE OF EVENTS

Provide a timeline of important events related to your injury or illness. Examples may include: Date of injury, Medical treatment, Claim filing, OWCP decisions, Light duty assignments, Work status changes.

Timeline of important events

DOCUMENT UPLOAD

Upload any supporting documents related to your case. Examples include: Medical reports, OWCP letters, CA forms, Light duty job offers, Supervisor correspondence, Other evidence.

Upload supporting documents

Drop files here or

Max. file size: 100 MB.

WHAT HELP ARE YOU SEEKING

What assistance are you seeking from Konexo?

What is the most urgent issue in your case?

CERTIFICATION AND SIGNATURE

Certification*

I certify the information provided in this intake form is true and correct to the best of my knowledge.

I understand this form is for case evaluation and preparation purposes only.

I consent to being contacted by PWR Retirement Group regarding this intake.

Printed Name

Digital Signature

Date Signed

OWCP Case Intake

FEDERAL EMPLOYMENT INFORMATION

INJURY OR ILLNESS INFORMATION

OWCP CLAIM INFORMATION

MEDICAL INFORMATION

COMPENSATION STATUS

CURRENT PROBLEM

WORK STATUS AND LIGHT DUTY

COMPENSATION STATUS

CURRENT PROBLEM

TIMELINE OF EVENTS

DOCUMENT UPLOAD

WHAT HELP ARE YOU SEEKING

CERTIFICATION AND SIGNATURE

Areas We Serve

Our Socials:

Stay updated to our newsletter

Services

Contact Us

Download the PWR App Now