Assigned By:                                                                Date:                                    Injury Date:

    Examiner:                                                                      Phone Number:                     Claim Number:

Claimant Information-

    Claimant Name:                                                             Date of Birth:                   Social Security Number:                 

    Mr. Mrs. Miss.                        

    Claimant Address                                                          Phone Number:                Email Address: 

    Complexion:                  Height:                        Weight:                        Eye Color:                    Hair Color:

    Marks or Scars:                                                    Nationality:                                           Married:                 

                        Yes    No

    Children:                       Number of Children:                  Ages:                                 Spouse's Name

    Yes    No                                 

    Vehicle Description if Known:

Employer Information-

    Name of Employer:                                                                         Phone Number:

    Address:                                                                           Contact:                                Salary:

    Claimant's Occupation at the Time of Injury:                   Date of Hire:                   Last Day Worked

Injury Information-

    Type of Injury:                                                             Present Complaints:

    Details of Injury:

Representation Information-

    Is the Claimant Represented:        If so, WCAB#                        Applicant's Attorney's Name                

             Yes     No                                     

Type of Investigation-

       AOE/COE-FULL INVESTIGATION (CLAIMANT'S STATEMENT, EMPLOYER LEGAL INVESTIGATION, SIGNED

                RELEASED).

        AOE/COE-CLAIMANT'S STATEMENT ONLY.

        AOE/COE-EMPLOYER LEVEL INVESTIGATION.

       OBTAIN MEDICAL RECORDS BY AUTHORIZATION/SDT FROM THE FOLLOWING:

       OBTAIN EMPLOYMENT RECORDS BY AUTHORIZATION/SDT FROM THE FOLLOWING:

       SERVICE OF PERSONAL SUBPOENA:

        ACTIVITY CHECK:

        SUB-ROSA INVESTIGATION FOR DAYS?

        LITIGATION CHECK PRIOR WCAB/CIVIL COMPLAINT FILINGS, TO DETERMINE IF THE CLAIMANT HAS

                 BEEN INVOLVED IN ANY RECENT TRAFFIC ACCIDENTS, LAW SUITS, DIVORCE FILINGS, OR PERSONAL

                 INJURY CASES.

        LOCATION OF WITNESSES.

       FINANCIAL INVESTIGATIONS.

    OTHER / SPECIAL INVESTIGATION

       DOES THE ASSIGNMENT REQUIRE RUSH HANDLING?

        HAS A HEARING DATE BEEN SET?   DATE:     TIME:

    PLACE OF TRIAL:

    If you wish original report/exhibits to be sent directly to your Counsel, please provide their name/ address below. We will send a copy of report and billing to your offices. Unless otherwise instructed below we will forward all originals directly to your offices.

    Attorney:     Firm:

    Address:                                                                      Phone#: