Date (mm/dd/yy):
Name:*
E-mail:*
Company:*
Company Address:
City
State/Province:
ZIP Code:
Phone:*
Fax:  
Claim #:
Date of Injury (mm/dd/yy):
Time of Injury: AM  PM

Insured
Name:
Address:
City:
State:            
Zip Code: 
Phone:   
Social Security #::
Date of Birth:
Occupation:
Type of Injury:
Attorney Involvement (specify):

Type of Investigation (please check)

Activities Check

Surveillance

Other

Background Investigation

Field Interview/Statement


Other
Please describe:

Interview/Statement
Secure
 Insured  Personnel Records
 Coworkers  Wage Records
 Witness(es) if any  Med Auth
 Employer  Job Description
 Supervisor  Medical Records
 Doctor  Police Reports
 Third Party  Coroner/Autopsy Report
 Police Officer(s)  Death Certificate
Other Other
   


Activities Check
  Find out if working         Active?  Playing sports?
  Canvas neighbors          Tail to work

  
Special Instructions:

Surveillance
Days Authorized:  
Film?   Yes        No
Special Instructions:

Physical Description
Height: Weight:  
Hair: Eyes:  
Build: Glasses:  
Complexion: Dress:
Facial Hair:      
Vehicles:
 
Hobbies and known
activities:

Background Investigation
  Civil Court Checks  Criminal Court Checks   Bankruptcy
  Obtain Medical Rec.   Driving History   Vehicles Owned
  Assets   Earnings Check   Police Reports
  Skip Trace   Consumer Filing Index
  Property Records

Further Information or Special Instructions:

 

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