TAGw - Online Worker's Compensation Pre-Investigation Questionnaire

If you prefer to mail or fax our Workers Compensation Pre-Investigation form to us instead of filling out the online form please download it from our website and send it to:

The Atlantis Group Worldwide, Inc.
5440 N. Cumberland Ave., Suite 230
Chicago, IL 60656
Fax: (773) 353-0072

Questionnaire Form

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

Claimant Information:
Last Name:	First Name:	Middle:
Date of Birth:	Home Phone:	Cell:
Gender:	Race: Height: Weight:
Address:	City: State: Zip:
Occupation:	Marital Status:
Location:	Location Details:
Spouse/Partner'sName:
Dependants’ Name and Ages:
Eyeglasses: Hair Length: Hair Color: Eye Color:
Distinguishing Physical Traits:
Behavioral Patterns (always stops at the same place for coffee, restaurants/bars/gyms frequented, habits, hobbies, friends, etc...):
Has claimant exhibited uncooperative behavior?
If Yes, describe (missed therapy appointments, etc...):
Known physical restrictions:
Description of claimant vehicles:
IWCC Case Number:
Have previous investigations been conducted?
If Yes, list dates/agencies:
Next Medical Appointment time/date/location:
Referral Date: (i.e. xx/xx/xx)	Client needs report by: (i.e. xx/xx/xx)
Photo Upload:
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?

Toll Free: (866) 696-9443
Licensed and Fully Insured. Illinois Licenses 117001393, 122001060

The Atlantis Group Worldwide Worker's Compensation Pre-Investigation Questionnaire

The Atlantis Group Worldwide
Worker's Compensation Pre-Investigation Questionnaire