Customer / Company Name:
|
|
Surveillance: |
|
| Claim Handler Name: |
|
Activity Check: |
|
| Phone (Including Area Code) |
|
Records Search: |
|
| Ext. |
|
Recorded Statement: |
|
| Full Name of Claimant: |
|
Claimant Profile: |
|
| Claim Number: |
|
Medical Profile: |
|
| Claimant Phone: |
|
Background Profile: |
|
| Claimant Street Address: |
|
Locate: |
|
| City: |
|
Marital Status Affidavit: |
| -
| State: |
|
Other: |
|
| Zip: |
|
If Surveillance, how many days? |
|
| Claimant DOB: |
|
|
|
| Claimant Social Security Number: |
|
| Injury: |
|
| Injury Date: Month/Day/Year |
|
| Special Instructions / Notes: |
|
