REQUEST FOR SERVICES



Insurance Company:
Date:
Adjuster/Investigator:
Phone:
Employer's Rep:
Tel:
May we contact?
Claimants work location:
Date of Hire:
Claimant:
Tel:
ADDRESS:
Checks sent to this address YES NO
Description:
Sex
DOB:
Hgt.
Wgt.
Hair:
Race:
Distinguishing features:
SSN:
Driver’s License No.
Vehicles:
Occupation:
Returned to work?
When?
Married?
Spouse’s Name?
Children?/Ages?
Claimant’s Atty:
Date of Injury:
Description of Accident:
Restrictions:
Alleged Injury/ Disability:

INTERVIEW ISSUES SECURE
Claimant AOE/COE Medical Authorization
Employer Employment Medical Records
Supervisor Serious & Willful Medical History Years
Witness, if any Subrogation Personnel Records
Third party Dependency Wage Statement
Other: Intoxication Employee Claim Form
Independent Contractor WCAB Records
Recorded Statements Motor Vehicle Police Report
Drivers History(Prior Accident) Civil/Criminal Records Search Municipal Superior
Counties: Sub Rosa (2) Days Activity Check Days
DMV ANI (Vehicles Registered) SSN Track All
Remarks:

SURVEILLANCE | INSURANCE FRAUD | BACKGROUND INVESTIGATIONS | WORKPLACE VIOLENCE | UNDERCOVER OPERATIONS
MISSING PERSONS | ROBBERY SUPPRESSION | ATTORNEY SERVICES | PRESS RELEASES | MEDIA INTERVIEWS | LINKS



Copyright (c) 2003 JMN Investigations