Assign A Case @ Leary and Associates, Inc. Investigators

Workers' Compensation Investigation Assignment

Date Assigned*

Rush (ASAP)
Routine

Due Date

Decision Date (if none, please enter N/A)*

Claim #*

Hearing Date

Medical Evaluation Date(s)

Employer Information

Employer Name*

Employer Contact Name

First Last

Employer Phone

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

OK to contact?

Yes
No

Claimant Information

PLEASE NOTE: If you use or have "auto-fill" enabled on your web browser, these fields may become pre-populated. Double check and make sure the correct information is entered before submitting the form.

Claimant Name*

First Last

Claimant Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Claimant Phone

Claimant Email

Last 4 Digits of Social Security Number

DOB

MM

DD

YYYY

D/I*

Job Title

D/H

LDW

RTW

Date Reported to Employer

Date Reported to Doctor

Instructions

Injuries (Include restrictions if applicable)

Remarks (why is investigation needed?)

Physical Description (If Applicable)

Height

Weight

Hair Color

Eye Color

Distinguishing Physical Characteristics

Vehicle Description (If Applicable)

Make/Model

Year

Color

License

Distinguishing Vehicle Characteristics

Additional Information

Location of Accident/Injury

Applicant Attorney

Treating Doctor

Assigned By

Company Name*

Contact Person*

First Last

Phone*

Email*

File