Your name:      Email:

Company:      Title:

Address:     City:    State:   Zip:

Telephone:    Ext.#:          Fax #:   

Legal Counsel:    Phone:   Ext.:  

Type of Claim:

Workers Comp    Disability   Automobile   General Liability    Property      Other

Claim #:    Date of Loss:    Injury:

Is the claimant out of work?     Lost time date:

Claimant Information:

Name:     Nickname:   Gender:

Address:   City:   State:   Zip:  

Phone:      SS/Drivers Lic.#:       DOB:


Personal:

Marital Status:  Married      Divorced     Separated      Widow      Single  

Name of spouse/companion:     No. of dependents

Child #1:   Age      Gender:   Male     Female     Unknown
Child #2:   Age      Gender:   Male     Female     Unknown
Child #3:   Age      Gender:   Male     Female     Unknown

Employer:    Job Title:   What days/hours?

Address:   City:   State:   Zip:

Sports/Hobbies/affiliation/clubs, etc:   

Favorite hangouts: 

Additional details: 

Medical:

Alleged injury:      Restrictions:

Physician(s):     Address:

City:      State:     Telephone:

Any upcoming appointments?          No    Yes          If yes, please specify IME Physician Physical Therapy Other

Conduct surveillance for this appointment?         No      Yes

Has there been previous investigations of this subject?       No      Yes

Purpose of this investigation:

Specific Instructions:

"Get the Truth. Get the Proof."