Insurance Investigation

Insurance Investigation
Due Date:

MonthDayYear
Date
Budget:
Hours Authorized:
Authorized By:
Type of Claim:
Specific Days:
Company/Agency:
Priority Level:
Requestor:
Are they Represented:
CLIENT SECTION
Clients Name:

First NameLast Name
Clients Number:
Please enter a valid phone number.Format: (000) 000-0000.
Clients Email:
example@example.com
Company:
Comments:
CLAIMANT SECTION
Claimants Name:

First NameLast Name
Claimants Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Claimants Email:
example@example.com
Claimants SSN:
Claimants DOB:
Claimants Sex:
Claimants Race:
Spouses Name:
Children:
(Color/Year/Make/Model/Tag
Claimants Vehicle:
(Color/Year/Make/Model/Tag
Photo of Claimant/Drivers License:

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Claimants Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claimants Employer:
Claimants Supervisor:

First NameLast Name
Supervisors Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Supervisors Email:
example@example.com
Employers Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INCIDENT DETAILS SECTION
Date of Incident:

MonthDayYear
Date
Time of Incident:
Type of Incident:
(Puncture, Slip & Fall, Lifting, etc.)
Part of the body Involved:
(Be specific - i.e. right shoulder injury, left knee, etc.)
Witness to Injury:
(Please list the name and contact information of any/all witnesses to the injury)
Work Loss Date:
(The date the claimant stopped working)
Medical Info:
(Is the claimant being seen by any doctors or specialist, if so please list the names and locations)
Medical Devices:
(Wheel chair, cane, medical boot, etc.)
Location/Address of Incident:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Assignment Instructions:
Has the employee lost time from work, if so, how long?
Has the employee returned to work?
Was the employee put on restricted duty?
At the time of the incident, was the employee...
Was medical treatment required?

YesNoUnsure
If yes, what type of treatment and where was it recieved?
Is there a follow-up appointment and if so, when is it?
Can restricted duty be accomodated?

YesNoUnsure
Is the Claimant Represented?
Attorneys Information:
Attorneys Information if represented (Name, Company, Phone, Email, Mailing Address, etc.)
Is Pretexting Allowed?:
Digital Investigation:
Do you require a background investigation, social media intelligence gathering?
Form Completed By:

First NameLast Name
Title/Position:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Legal Eye Investigations has gone paperless. All evidence (reports, videos/photos, invoices) will be delivered through our secure case management system.
If you would prefer or require hard copies of any evidence obtained, please check the box(es) below:

ReportsVideosPhotosInvoices
SPECIAL INSTRUCTIONS FOR THE AGENCY - SPECIFIC INFORMATION FOR INVESTIGATION:
Upload Documents:

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We are committed to providing you with options that best suit your needs and preferences, including discreet billing. You have the choice to have your bill labeled as "RAWCO Maintenance" for the utmost privacy and discretion. However, if there are business-related reasons for you to prefer our agency name, "Legal Eye Investigations, LLC," on the billing statement, we can accommodate that as well. Your satisfaction and comfort are our priorities, so please choose the billing option that aligns with your requirements.
Billing Options:
Thank you for choosing Legal Eye Investigations, LLC.
Should be Empty:

Insurance Investigation

CLIENT SECTION

CLAIMANT SECTION

INCIDENT DETAILS SECTION