WORKERS COMPENSATION INVESTIGATION

 
 

 
 

Company:

Examiner:

Address:

Claim No.:

Defense Attorney:

Phone No.:

Address:

Requestors E-mail:

Case Title:

Phone No.:
Employer Information

Employer:

Contact::

Address:

Phone No.:
Employee Information

Name:

SSN:

Address:

Job Title:

Phone No.:

Hire Date:

Prior Address:

Injury Date:

DOB:

Eyes:

Weight::

Height:

Hair:
   

Injury:

 

Restrictions:

 

Applicant's Attorney:

Phone No.:
 
Investigation Interview/Statement Obtain
 AOE/COE  Employee  WCAB Records
 Activity Check  Co-workers  Personel Records

 Surveillance

  Witness(es)  Wage Records
 Employment  Employer  Medical Records
 Serious & Willful  Supervisor  Medical Authorization
 Dependency  Doctor(s)  Job Description
 Court Index  Third Party  Police Report
 Subrogation  Police Officer(s)  Death Certificate
 Other
 		  Other
 		  Other
 
 
 
Rush Order
 
Need by:
 
 
   
Call before Commencing Assignment
Special Instructions:  
 
   

Assignment Forms

Insurance Investigation Request

Workers Compensation Request

Subpoena Preparation/Service Request

Professional Security & Counter Security Equipment: