Investigation type: WC Auto GL Trial Prep Disability Other If Other, please describe: COMPANY Company Name: Phone: Fax: Address: City: State: Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip: Today's date: Adjuster/Contact: Email: Claim # WCB # D/L: CLAIMANT Last Name: First Name: Phone: Address: City: State: Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip: Occupation: Injury: DOB: SS#: Sex: Male Female Height: '" Weight: lbs. Hair Color: Ethnicity: Location of Incident: Additional Information Regarding Incident and/or Claimant (If auto, please provide vehicle(s) and driver(s): Describe the event here. CLAIMANT ATTORNEY Name: Phone: Address: City: State: Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip: Insured: Insured Address: Contact Name: Broker Name: Phone: ASSIGNMENTS / DATE(S) REQUESTED: (check all that apply) Surveillance Background Search Take Recorded or Signed Statement Obtain Sworn Affidavit Trial Preparation Activity Check Criminal History Search Scene Photos or Video Process Service Alive & Well Check Prior Litigation History Video Tape EBT Subrogation Report Locate Client or Witness Report Asset Search Video Tape IME Provide Police Report Med-Clinic Inspection Obtain Medical Records Construction Accident Obtain 3rd-Party Information Conduct Witness Canvass 15-8 Recovery Labor Law 240