Referral information

2525 Robinhood Street
Houston, Texas 77005

[e-mail]
www.sneedmitchell.com

+1 281.798.9434 WS

DBA CLIENT/CLAIM INFORMATION INTAKE SHEET

1. 
   REFERRAL INFORMATION PLEASE USE *MONTH/DATE/YEAR* FOR ALL DATES
   

Today’s Date: August 31, 2023
Who referred you to our firm? Frind of mine Albert Khamraev
Have you had an attorney for this claim before? If yes, who? No
Have you had another Defense Base Act claim before? If so, when and what happened? Note in the space below:

No I Haven’t had that claim before

2. 
   PERSONAL INFORMATION PLEASE USE *MONTH/DATE/YEAR* FOR ALL DATES
   

Your Name (Please use First Name, Middle Name, Surname/Last Name):
Jamshid Shakirov Zaripovich

X

X

Marital Status (Married / Single): Sex: (M / F) Nationality: Uzbek

Primary Language: Uzbek Secondary Language: Russian, English
Date of Birth: May 07, 1980 Email: [e-mail]
Phone Number: [phone] Alternate Phone: [phone]
Your Address (including city/district/region):
5^th mikro district 24^th house 16^th flat Kashkadarya region Karshi city Uzbekistan

3. 
   EMPLOYER INFORMATION PLEASE USE *MONTH/DATE/YEAR* FOR ALL DATES
   

Name of Employer: KBR

Address of Employer: Texas, Houston
Your Job Title: Operations Coordinator (Travel) Wages per month:
Your earnings for year prior to injury: 150 000-160 000 USD Days worked per week: 7
Date of Hire: September 30, 2005 Last Date Overseas for Employer: July 10, 2008
Supervisor Name: DeEtte Bryson, Jesse Steadman Total years worked for employer: 3
Reason for leaving employer: Voluntary demobilization

4. 
   DBA CLAIM & INSURANCE CARRIER INFORMATION (if applicable/available)
   

Name of insurance company: Adjuster Name:
Adjuster Phone/Email:
Claim Number: U.S Dept of Labor OWCP No.:

5. 
   ACCIDENT INFORMATION PLEASE USE *MONTH/DATE/YEAR* FOR ALL DATES
   

Date of Injury: Autumn 2007 Location of Accident: Kandahar Afghanistan
NOTE: If your injury developed over time, please list the last date you worked overseas as injury date.
Body part(s) injured: PTSD
NOTE: if you have multiple injuries with different injury dates, please explain below: