INSURANCE CLAIM INVESTIGATION FORM: Workplace Accident. Questions Call Our Office (800) 733-1950 Due Date Client File# Claim# *RUSH ASSIGNMENT NOYES1 Week2 Weeks3 Weeks4 WeeksOther CLIENT / TPA / COMPANY Authorized by: Name * Phone Direct Phone# Email Address Comments INSURED NAME INSURED ADDRESS INSURED CONTACT INSURED CONTACT PHONE Direct Phone# Email SUBJECT INFORMATION & TYPE OF INVESTIGATION Claim Number Hours Authorized Other Date Requested Weekend Request Date and Time of Injury Agency w/ Report Incident# Claimant's Name Date of BIrth Gender Male Female Claimant's Address Claimant's Home Phone Social Security Number D.O.I. Marital Status Doctor or Health-care Med Date & Time Claimant Description State Driver's License# Alleged Injury / Restrictions Date of Hire Work Schedule Witness (1) Contact Info Witness (1) Witness (2) Contact Info Witness (2) AOE-COE / SUBROGATION / STATEMENTS /ACCIDENTS SCENE CLAIMANT MEDICAL AUTHORIZATION CLAIMANT MEDICAL AUTHORIZATION WCAB CASE HISTORY SEARCH WCAB CASE HISTORY SEARCH EDEX RECORDS EDEX RECORDS Checkboxes Criminal Records Civil Court Records Federal Court Records Police Report* Other DMV Records Medical Records Employment Records Wage and Hour Records Personnel Records Skip Trace and Locate Comp Report Death Records EMPLOYER CONTACT INFORMATION Employer Employer Phone Employer Address Return to Work Coordinator Phone Supervisor Name Phone Department / Work Site Work Site Address SPECIAL INSTRUCTIONS FOR AGENCY - SPECIFIC INFORMATION FOR INVESTIGATION SPECIAL INSTRUCTIONS FOR AGENCY - SPECIFIC INFORMATION FOR INVESTIGATION Upload Documents Drop a file here or click to upload Choose File Maximum file size: 516MB Name of Representative Authorizing Services * BY SUBMITTING THIS FORM TO THE AGENCY YOU AFFIRMATIVELY AGREE TO THE FOLLOWING: 1. LIMITATIONS OF USE AND LIABILITY 2. ALL INFORMATION IS CORRECT. Limitations of Liability. While the information contained in the report(s) provided has been obtained from records data sources deemed reliable, its accuracy cannot be guaranteed due to potential human error in the actual recording of the records. Since this information is not owned by Stryker Investigation Services Inc., and since records data on any one individual, group of individuals, company, or companies can be contained in more than one repository, Stryker Investigation Services Inc., can only rely on its accuracy from the records data sources presently available at the time of the search. This information is furnished for your exclusive use and accepted by you without any liability whatsoever on the part of Stryker Investigation Services Inc., its sources, officers, agents or employees. Furthermore, you agree to indemnify Stryker Investigation Services Inc., its sources, agents, and employees of any liability for the use of this information. Captcha CLOSING COMMENTS:We sincerely appreciate your confidence in Stryker and look forward to the privilege of working with you on this assignment.If you have any questions, please call us at (800) 733-1950 Thank you for this assignment. If you are human, leave this field blank.
