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 NameClaim NumberInvestigative Services/Attorney File NumberDate of Injury/LossExample: 12/15/15 - 12/31/15 or 12/15/15 - PresentDue Date 90-Day Statutory Date EMPLOYER DATANameCompany NameEmail PhoneAddressDEFENSE ATTORNEYNameCompany NameEmail PhoneAddress EMPLOYEE/APPLICANTNameClaimant/Applicant AddressJob Title/PositionDepartmentWork PhoneHome PhoneDate of Birth Social Security NumberHire Date InjuryTTD StatusYesNoModified DutyRestrictionsApplicant's AttorneyAttorney 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 NameSupervisor PhoneSupervisor Email Recorded Statement WitnessesList WitnessesNamePhone Police Report InformationPolice AgencyReport NumberSurveillance InformationNumber of Days or Authorized Amount ($)Claimant Description Race , Height , Weight , Hair Length , Hair Color , EyesVehicle(s) Description Vehicle Year , Make , Model , ColorMedical Follow Yes Appointment Date Appointment Time : HH MM AM PM Type of AppointmentMedical, QME, PQME, OtherDoctor NameDoctor PhoneAppointment Address Street Address Address Line 2 City State Zip Appointment Notes Legal Follow Yes Legal Date Legal Time : HH MM AM PM Type of AppointmentDefense Attorney NameDefense Attorney PhoneLegal Appointment Address Street Address Address Line 2 City State Zip Special Instructions Photos / Wage Statements / Medical Authorizations Upload Drop files here or Accepted file types: jpg, gif, png, pdf, jpeg. PhoneThis field is for validation purposes and should be left unchanged.
