Life & Disability Claim

    Date:

    Name:

    E-Mail:

    Company:

    Company
    Address:

    State:

 

ZIP/Postal Code:

    Phone:

Fax:

    Policy # :

Claim #:

    Effective
    Dates:

 


TO

 
    Date of
    Loss: 

    Time of
    Loss:

  

A.M.

P.M.

 ___________________________________________________

Insured
 

    Name:

    Address:
    State: Zip Code:
    Phone: S.S.#
    Date of Birth:
    Occupation
    Type of Injury:
    Attorney Involvement:

_______________________________________________

   Type of Invest
    Activities Check:


Surveillance:
    Other: Background Invest:

 

  Special Instructions

  Interview / Statement

    Insured:


Co Workers:
    Witness(es): Employer:
    Supervisor: Doctor:
    Police Officer: Other:

  Secure

    Personal Records:


Wage Records:
    Medical Authorization: Job Description:
    Death Certificate: Police Reports:
    Coroner/Autopsy Report: Medical Records:
    Other:    

_______________________________________________

Type of Assignment

  Activities Check

    Find out if working:


Active?:
    Canvass Neighbors: Playing Sports?:

    Tail to work:
   

  Surveillance

    Days Authorized:


    Film?

    Still Photos?

  Physical Description

    Height:


Weight:
    Hair: Eyes:
    Build: Glasses:
    Complexion: Dress:
    Facial Hair: Vehicles:

  Background Investigation

    Obtain Med Records:

Skip Trace:
    Bankruptcy: Police:
    Consumer Filing Index: Earnings:
    Criminal Court Records Check: Property:
    Civil Court Reports Check: Driving Hist:
    Consumer Filing Index: Vehicles:

  Hobbies & Known Activities

  Further Information or Instructions