HDI Investigation & Executive Protection Service, Inc Workers’ Compensation

HDI Investigation & Executive Protection Service, Inc

Worker's Compensation – Assignment Sheet

Assigned By:

Date:

Client Information:

Client:

Contact Person:

Address:

Telephone:

Email:

Claimant Information:

Claimant’s Name:

DOB:

Address:

Sex:

Race:

Marital Status:

SSN:

Photo:

Height:

Weight:

Hair:

Bald:

Facial Hair:

Glasses:

Phone#:

Prior Surveillance:

Date:

Known Activities:

Misc.

Medical Information:

Date of Injury:

Type of Injury:

Alleged Claimant Restrictions:

Investigative Work to be conducted by HDI

Surveillance:

Hours:

Background Check:

Locate Subject:

Activity Check:

Alive & Well Check:

Other:

Client Directives and/or Constraints:

Insured Information:

Insured:

Insured Contact:

Address:

Ok to contact insured?

Phone#: