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Claims Investigations - Assignment Form

CLIENT INFORMATION
Name:
Company: Title:
Address:
City: State: Zip Code:
Phone Number:
Ext.: 		Fax Number:
E-mail Address:

CLAIM INFORMATION
Incident Date: Claim Number:
Insured:
Type of Claim: Worker's Comp.Liability Disability Auto
Property Life Medical Malpractice Other

If other, please describe:

INVESTIGATION INFORMATION
Type of Investigation: Surveillance Neighborhood Canvass
In-house Research Locates Other

If other, please describe:

Personal Interviews:

Statement:

Personal Contact:

Transcribed?:

Disability Personal Contact:

Accident Investigations: (scene photos, diagram, reports and witness canvass)


Scene Photos and Diagram:

Witness Canvass:

Vehicle Inspection:

Document Review:


INVESTIGATION PARAMETERS
Budget: or Number of Days/Hours:

Turnaround:

Has there been a prior investigation on this case?: Yes No

If yes, agency who completed the assignment?:

If Diogenes LLC, please provide case number.:

If another company, is their report available for review?:

Yes No

Has surveillance conducted by other been compromised?:

Yes No


SUBJECT'S INFORMATION
Last Name: First Name:

Alias/Nickname:

Address:
City: State: Zip Code:
Phone Number: Additional Contact Number:
DOB: Social Security Number:

SUBJECT'S PHYSICAL DESCRIPTION
Race: Sex: Male Female
Hair Color: Length of Hair:
Eyes: Height: Weight:

Other Notable Characteristics (glasses, facial hair, tattoos, etc...):


SUBJECT'S PERSONAL INFORMATION
Marital Status:
Spouse's Name (if applicable):
Children's ages and number of:

Vehicle Information: Registration #, Make, Model and Color:

Known Hobbies and/or Activities:

Is subject currently employed?: Yes No

If yes, where:
Occupation/work hours:

Is subject represented?: Yes No

If yes, Attorney's name:
Any legal action pending?: Yes No

Are there upcoming scheduled hearings, depositions, trials? Yes No

If yes, times, dates, and locations if known:

Are there future scheduled medical or physical therapy appointments? Yes No

If yes, times, dates, and locations if known:


INJURY DETAILS

Alleged Injury:

Lower Lumbar Cervical Back
Arm: R L Elbow: R L Wrist/Hand: R L
Leg: R L Knee: R L Ankle/Foot: R L
Other (please describe):

RESTRICTIONS
Temporary Total Disability Temporary Partial Disability

Light Duty Release with restrictions (list restrictions):

CANNOT:

Work Drive Run Ride Bike
Bend Lift

Twist

 Stoop
Squat

Pull

 Push Other
If other, please specify:

ADDITIONAL INFORMATION/SPECIFIC
INSTRUCTIONS/OBJECTIVES FOR INVESTIGATION:

Do you have any additional information such as a subject photograph, personal injury report, police report, database search, previous investigation results, statements, depositions, etc.?

Yes. I will fax it to (702) 548-9566.
No. All pertinent information is included.

Investigative Services Agreement has been fully executed and submitted to Diogenes LLC. If not, please submit with this intake form.

 

 



If you have any questions, you may contact us by telephone (203.264.6802) or via email.

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