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 "Helpful Hints for the user when requesting an Assignment”
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The Referral Sheet is designed to request an assignment for multiple types of investigative services. Here are a few helpful hints when filling out a referral request.
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Insurer/Client
The Company, Department or Third Party Administrator to which the requester is employed/represent. |
Date
The date of the request. |
Requested by
The Individual person requesting the referral or the person whom the final report should be addressed to. |
Telephone
A contact number to contact the requester. |
Claim #
The claim number assigned to the claimant’s case. This may not apply to every referral and is not a mandatory requirement. |
Date of Loss
The date that the claimant alleged the injury or loss. This may not apply to every referral and is not a mandatory requirement. |
Type of Investigation Request
Please type or write any of the following: Worker’s Compensation Surveillance, EEO Services, Activities Check, Pre-employment check, Background check, Recorded statement, Written Statement, or other. |
Days Requested
Please indicate any specific date or time that you would like the request performed. |
Subject’s Information
This information is strictly related to the subject/claimant regarding the assignment. In order to help us quickly expedite your request, it is mandatory that one of the following combined data entries must be given:
Subject’s full name (first, last) and Date of birth
Subject’s full name (first, last) and Social Security
All additional information that is requested for the subject/claimant will be helpful but is optional. Please keep in mind that the more information provided regarding the subject/claimant the faster and effective the results will be. |
Sex, Height, Weight
This information is optional. The height and weight can be estimated. |
General Description
This information can provide any uniqueness regarding the subject/claimant for ex. Blonde long hair, dark short hair, a rose tattoo on the lower left leg, a scar on the right arm, etc… |
Last Known Address
This information is optional. Even if a last known address is several years old it would be helpful. |
Injury
This would be required for a worker’s compensation surveillance request. Please provide location of alleged bodily injury. |
Any Scheduled Appointments
This information is important and commonly needed for worker’s compensation assignments. This information is optional. |
Doctor’s
If the subject/claimant has a doctor’s appointment please provide the doctor’s name. This information is mandatory. |
Doctor’s address
If the subject/claimant has a doctor’s appointment please provide the doctor’s address. This information is optional. |
Is this subject/claimant working light duty?
This information is important and commonly needed for worker’s compensation surveillance assignments. If the answer is yes, please provide all pertinent information. This information is optional. |
Is there a scheduled deposition or mediation?
This information is important and commonly needed for worker’s compensation surveillance assignments. This information is optional. |
Have there ever been any previous Investigations on this subject/claimant?
This is very important for all assignments. If the answer is yes, please provide the dates, and report if available. |
Other Information
This entry is provided for any additional information or details you the requestor feel is important for us to know regarding your assignment. |
