INSURANCE INVESTIGATION REQUEST
WORKSHEET
Claim No:
Adjuster:
E-Mail:
Date of Loss:
Contact Phone:
Type of Claim:
Worker's Compensation
Auto Accident
Product Libility
Uninsured Motorist
Medical Malpratice
No Fault
Slip & Fall Accident
Other
Length of Assignment:
Authorization Limit:
Specific Instructions to Investigators:
Subject/Claimant Name:
Current Address:
Home Phone:
Subject/Claimant Description:
Sex:
Male
Female
Race:
Height:
Weight:
Hair Color:
Eye Color:
D.O.B.
(MM/DD/YYYY)
SSN:
Employer:
Occupation:
Other Data, Appointments, Etc.