This assignment is to:
Assign a New Case
Re-open a Case
Surveillance
Activity Check
Background / Records Search
AOE-COE
Service of Process
Copy Service
CLIENT INFORMATION:
Your Name
Your Organization
Claim Number
Email Address
Confirm Email Address
Phone
-
-
Fax
-
-
Address
City
State
California
Alabama
Alaska
Alberta
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
CLAIMANT/PLAINTIFF INFORMATION:
First Name
Last Name
Address
City
State
California
Alabama
Alaska
Alberta
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Telephone
-
-
Social Security
-
-
Date of Birth
Occupation
Represented?
Yes
No
Description:
TREATING DOCTOR:
Doctor's name
Address
City
State
California
Alabama
Alaska
Alberta
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Telephone
-
-
Treatment Schedule
INSURED/EMPLOYER:
Name
Address
City
State
California
Alabama
Alaska
Alberta
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Contact
Telephone
-
-
DETAILS OF ACCIDENT/INJURY:
Date of Injury
Injury
Indications for Fraud /
Questions to be Answered
AOE/COE INSTRUCTIONS:
Take the statement of :
Claimant
Supervisor
Witness (if any)
Employer
Other
Special Instructions:
SURVEILLANCE INSTRUCTIONS:
Hours of Surveillance Authorized:
Specific days, if any, requested:
Why these specific days?
Has surveillance been conducted previously on this claimant?
Yes
No