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::

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