*
Name:
*
Company:
Address:
*
Phone:
Fax:
*
E-Mail:
City:
State:
Zip:
*
Claim #:
*
Address:
*
Subject Name:
*
Phone:
*
City:
*
State:
*
Zip:
*
DOB:
(mm/dd/yy format)
*
SSN:
*
Represented:
Yes
No
*
Type of Claim:
Worker's Comp
Liability
Auto
Disability
Medical Malpractice
Life
Other
*
Injury:
*
Date of Loss:
(mm/dd/yy format)
*
Employer/Insured:
Employer Contact:
Restrictions:
Employer Phone:
Employer E-Mail:
Height:
Weight:
Job Duty:
Race:
Hair Color:
Sex:
Male
Female
Subject Currently Employed:
Yes
No
Unknown
Restricted/Light Duty
Other
Comments:
Surveillance
Authorized Hours:
16
24
32
Other
Complete Date:
Comments/Instructions:
Remote Surveillance
Authorized Days:
7
5
3
Complete Date:
Comments/Instructions:
Background Investigation
Criminal Check
Civil Check
Motor Vehicle Reporting
Complete Database Reporting
Business Interests
WC Accident Check
Auto Accident Check
Driver's License Check
Motor Vehicle Tag Search
Locate/Skiptrace
SS Number Verification
Asset Income Report
Other:
Comments/Instructions:
Investigative Canvasses
Extended Hospital Canvass
Eighteen (18) Hospital Canvass
Twelve (12) Hospital Canvass
Eighteen (18) Pharmacy Canvass
Twelve (12) Pharmacy Canvass
Eighteen (18) Clinic Canvass
Twelve (12) Clinic Canvass
Gym and Health Club Canvass
Golf Club and Course Canvass
Comments/Instructions:
Activity Check
Comments/Instructions:
Special Investigations
Special Investigative Unit (SIU) Services
Recorded Statements and Interviews
Witness Location
Translations
AOE/COE
Accident Scene Investigation
Workers Compensation
Video Inspections
C.A.T. duty
Other:
Report:
E-Mail
Hard Copy Mailed
Invoice:
E-Voice
Hard Copy Mailed
R-Vision:
Yes
No
Video:
VHS
CD-ROM
Status Update:
Verbal Update
E-Mail Update
No Update
Comments/
Instructions:
C.C. Parties:
Report
Video Information:
Report
Video Information:
Report
Video Information:
Report
Video Information:
(*Required fields)
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