Life and Disability Investigation Form Life and Disability Investigation Please note: * denotes fields that are required to be filled in. Name * Email Address * Company * Company Address * City * State/Province * Zip Code * Phone Number * Fax Number Claim Number Date of Injury (mm/dd/yy) Time of Injury 121234567891011 : 0030 AMPM Insured Name Address City State Zip Code Phone Number Date of Birth Social Security # Occupation Type of Injury Attorney Involvement (specify) Type of Investigation*Please select the type of investigation(s) to be completed. Activities Check Background Investigation Surveillance Field Interview/Statement OtherOther Interview/Statement Insured Coworkers Witness(es) if any Employer Supervisor Doctor Third Party Police Officer(s) OtherOther Secure Personnel Records Wage Records Med Authorization Job Description Medical Records Police Reports Coroner/Autopsy Report Death Certificate OtherOther Activities Check Activities Check Find out if working Active? Playing sports? Canvasneighbors Tail to work Special Instructions Surveillance Days Authorized Days Authorized Film? Yes No Special Instructions Physical Description Height Weight Hair Eyes Build Glasses Complexion Dress Facial Hair Vehicles Hobbies and known activities Background Check Background Check Civil Court Checks Criminal Court Checks Bankruptcy Obtain Medical Records Driving History Vehicle Owned Assets Earnings Check Policy Reports Skip Trace Consumer Filing Index Property Reports Further Information or Special Instructions Other Please Describe reCAPTCHA If you are human, leave this field blank.
