Workers Compensation Investigation Form Workers Compensation 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 Employer Name Address City State Zip Code Business Phone Number Person to Contact Contact's Phone Number Employee Name Address City State Zip Code Phone Number Date of Birth Social Security # Occupation Type of Injury Type Of Assignment*Please select the type of assignment(s) to be completed AOE/COE Background Investigation Activities Check Surveillance OtherOther AOE/COE At Issue Subrogation Apportionment Employment Dependency Initial Aggressor Independent Contractor Other Insurance Serious & Willful Going & Coming Concurrent Employment Wrongful Termination or 132A Interview/Statement Employee Coworkers Witnesses 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 Report Death Certificate WCAB Records OtherOther Special Instructions Activities Check Activities Check Find out if working Active? Playing sports? Canvas neighbors Tail to work Surveillance Days Authorized 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 WCAB Search Driving History Arrest Records Assets Earnings Check Police Reports Skip Trace Consumer Filing Index Property Records Other Please Describe Further Information or Special Instructions: reCAPTCHA If you are human, leave this field blank.