ASSIGNMENT FORM Please complete as much information as you feel is relevant and be sure to provide us with your contact information. We will contact you to confirm receipt and to obtain additional information if needed. Step 1 of 3 33% CLIENT INFORMATIONName* Company Name* Email* Phone*CLAIM DATAClaimant/Applicant Name Claim Number Investigative Services/Attorney File Number Date of Injury/Loss Example: 12/15/15 - 12/31/15 or 12/15/15 - PresentDue Date MM slash DD slash YYYY 90-Day Statutory Date MM slash DD slash YYYY EMPLOYER DATAName Company Name Email PhoneAddress DEFENSE ATTORNEYName Company Name Email PhoneAddress EMPLOYEE/APPLICANTName Claimant/Applicant Address Job Title/Position Department Work PhoneHome PhoneDate of Birth MM slash DD slash YYYY Social Security Number Hire Date MM slash DD slash YYYY Injury TTD Status Yes No Modified Duty Restrictions Applicant's Attorney Attorney Phone ASSIGNMENTSPlease check all that apply.AOE/COE Recorded Statement Employee Recorded Statement Employer Recorded Statement Supervisor Recorded Statement Witnesses/Co-Workers Medical Authorization Police Report Personnel Records Wage Records Surveillance Supervisor InformationSupervisor Name Supervisor PhoneSupervisor Email Recorded Statement WitnessesList WitnessesNamePhone Police Report InformationPolice Agency Report Number Surveillance InformationNumber of Days or Authorized Amount ($) Claimant DescriptionRace , Height , Weight , Hair Length , Hair Color , EyesVehicle(s) DescriptionVehicle Year , Make , Model , ColorMedical Follow Yes Appointment Date MM slash DD slash YYYY Appointment Time : Hours Minutes AM PM AM/PM Type of Appointment Medical, QME, PQME, OtherDoctor Name Doctor PhoneAppointment Address Street Address Address Line 2 City State Zip Appointment NotesLegal Follow Yes Legal Date MM slash DD slash YYYY Legal Time : Hours Minutes AM PM AM/PM Type of Appointment Defense Attorney Name Defense Attorney PhoneLegal Appointment Address Street Address Address Line 2 City State Zip Special InstructionsPhotos / Wage Statements / Medical Authorizations Upload Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 2 GB, Max. files: 10. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
