WORKER'S COMPENSATION INVESTIGATIVE FORM

Today's Date: May 21, 2012
IP Address Logged: 38.107.179.214

If you prefer to mail or fax our Workers Compensation Investigative form to us instead of filling out the online form please download it from our website.

Type:
Surveillance	Recorded Statement	Accident Scene Documentation
Well-Being Check	Other:

Subject Information:
Last Name:     First Name:
Middle Name:
Date of Birth:	Home Phone:	Cell:
Gender: Male Female	Race:      Height:      Weight:
Address:	City:      State:      Zip:
Occupation:	Marital Status: Divorced Married Single Unknown Domestic Partnership
Location: Employment Location	Location Details:
Spouse/Partner'sName:
Dependants’ Name and Ages:
Eyeglasses: Yes No Occasionally      Hair Length:      Hair Color: None Black Blond Blue Brown Gray Red      Eye Color: Blue Brown Green Hazel Gray
Distinguishing Physical Traits:
Behavioral Patterns (always stops at the same place for coffee, restaurants/bars/gyms frequented, habits, hobbies, friends, etc...):
If this is a Worker's Compensation investigation, has the claimant exhibited uncooperative behavior?:
Known physical restrictions:
Description of subject vehicles:
IWCC Case Number:
Number of Days Authorized:
Have previous investigations been conducted? Yes No
If Yes, list dates/agencies:
If this is a Worker's Compensation investigation, when is the next medical appointment time/date/location?:
Referral Date: ...	Client needs report by: ...
Photo Upload: E-Mail info@theatlantisgroup.us if you have more photos
Social Security Number: (i.e. xxx-xx-xxxx)
Special instructions and/or comments:

Requester Information:
Last Name:     First Name:
Phone: Fax:
Company Name:
Address (No PO Boxes):		Suite:
City:      State:      Zip:
E-Mail:
Claim Number:	Claim Type:	Insured:
How would you like to receive the report? EMail/Online Overnight 2nd Day Priority Mail

Toll Free: (866) 696-9443
E-Mail: info@theatlantisgroup.us

Licensed and Fully Insured. Illinois Licenses 117001393, 122001060