www.voicesflorida.com

VOICES, Inc. On-line Membership Application

Membership information remains private and is not distributed.

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This was done because Bravenet software for forms submission actually works; the other site's software is inferior.
Your confidentiality will not be compromised.

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Others will need to download an application. .doc format   .pdf format

1.   * New or   Renewing Member?
2.    Renewing members: Is this an update of your information?   yes     no
3.   * Name
4.   * Address
         City, State, Zip

5.   Residence phone with area code
6.   Cell phone with area code
7.   Work phone with area code
8.   * Email address
9.   Occupation (pre-injury)
10. * Injured worker? yes  no  If yes, which state  
11. * What is your interest in joining VOICES, Inc?


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For Injured Workers Only

12.  Date of Birth

13.  Date of Injury

14.  Severity of Injury:   mild   moderate    severe

15.  Diagnosis if known

16.  Employer when injured

17.  Employer's method of providing workers compensation coverage: Insurance Carrier or Self-Insured?

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18.  Date workers compensation benefits began (mm/dd/xxxx)

19.  Are you totally disabled (by your state's legal definition)?  yes    no

20.  Are you on SSD (Social Security Disability)?  yes     no

21.  Attorney's name, if you have one

22.  Please describe how you have been treated as an injured worker by your employer and insurance provider:

23. Please describe how you have been treated as an injured worker by your medical providers and attorney:

24.   Please describe how you have been treated as an injured worker by your state's Employee Assistance Program:

25.  We welcome other comments.

Thank you for your information. We must all work together in order to make positive changes in the workers comp system.
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Please click only once to send your information. You will be redirected to a site to confirm your information. If it is correct, continue; if not, come back here and try again. (You click send again after you make corrections or additions -but just once, please.) After you send this form, you will be directed to a page where there is information about making a financial contribution to VOICES Inc. Any donation is very welcome. There is NO obligation. All membership fees are waived for persons who cannot at this time contribute. At that point you can go to anyplace you want on or off the site.

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This page was updated August 3, 2004.
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