INSURANCE CLAIM INVESTIGATION FORM:

Workplace Accident. Slip & Fall. AOE/COE Statements, Investigations. Workers' Comp. Subrosa Surveillance.

Questions? Call Our Office (800) 733-1950

Today's Date:

*RUSH ASSIGNMENT

LAW FIRM / BUSINESS / INSURANCE COMPANY / TPA: *

NAME OF LAW FIRM / CLIENT / TPA / COMPANY: Who is requesting the investigation?

Authorized by: *

Who has authorized the investigation?

LAW FIRM / BUSINESS / INSURANCE COMPANY / TPA:

Law Firm

Business

Insurance Company

TPA

Please select the category that best describes your professional capacity in this matter:

Client File#

Claim#

Address:

LAW FIRM / CLIENT / TPA / COMPANY Investigation Requestor's Address:

Name:

Contact Person:

Phone:

Example (999)-999-9999

Direct Phone#

Example (999)-999-9999

Email:

Contact Person:

Stryker No Longer Accepts Checks through the USPS Mail. Our preferred method of payment is Credit Card, ACH Transfer, or Direct Deposit

Questions? Call Our Office (800) 733-1950

INVOICE PAYMENT & AGREEMENT INSTRUCTIONS:

Optional information. As you complete this investigation form, you'll encounter a collapsible section for "Invoice and Agreement Delivery." If you need the invoice and service agreement sent directly to your client, expand this section using the down arrow, and complete the required delivery information. If you handle these documents internally within your firm, simply leave this section collapsed and proceed to the next portion of the form. Only complete this section if documents are being sent directly to your client. If you're unsure about your firm's preferred delivery method, please contact our office for guidance.

Is Stryker forwarding the invoice and agreement to someone else? If not, indicate no. If yes, indicate who?

YES

NO

Name of Company Receiving the Invoice:

Address of Company Receiving Invoice:

Name:

First Name. To whom do we address the email for the invoice?

Last Name

Email:

Where do we send the email for the invoice?

Phone:

Phone number of contact per person for the invoice.

Agreement Recipient Name:

Agreement Email:

Comments

If you need to explain the invoice details, the investigation circumstances, or provide the agency with additional details, please do so.

IF THE INSURANCE COVERAGE IS NOT "AT ISSUE" IN THIS MATTER, PLEASE INDICATE WHETHER THE COVERAGE IS ESTABLISHED:

Yes,

No.

If yes: INSURED NAME:

If coverage = Yes: INSURED NAME:

INSURED ADDRESS:

INSURED CONTACT:

Contact Person's Name:

INSURED CONTACT PHONE:

Contact Person's Phone:

EMAIL:

Contact Person's email:

If No: BUSINESS INFORMATION:

If no: BUSINESS / ENTITY NAME:

If coverage = No: BUSINESS/ENTITY NAME:

If no: BUSINESS / ENTITY ADDRESS:

BUSINESS / ENTITY CONTACT PERSON:

Contact Person's Name: first and last.

BUSINESS / ENTITY PHONE:

Contact Person's Phone:

SUBJECT/ CLAIMANT INFORMATION & TYPE OF INVESTIGATION

Comments / Explain Other Services:

Claim Number:

Date and of Injury:

Due Date Requested:

Date of Hire:

Work Schedule:

SURVEILLANCE: Weekend Request

SURVEILLANCE: Hours Authorized

OBTAIN POLICE REPORT: Agency w/ Report

POLICE REPORT: Incident Number:

Claimant's Name:

Date of BIrth:

Gender:

Male

Female

Claimant's Address:

Claimant's Home Phone:

Social Security Number:

Marital Status

Doctor or Health-care

Med Date & Time

Driver's License State: Dropdown

Driver's License Number:

ID CARD:

Claimant Description:

Alleged Injury / Restrictions:

AOE-COE / SUBROGATION / STATEMENTS /ACCIDENTS SCENE

CLAIMANT MEDICAL AUTHORIZATION

WCAB CASE HISTORY SEARCH

EDEX RECORDS

Witness (1)

Contact Info Witness (1)

Witness (2)

Contact Info Witness (2)

EMPLOYER CONTACT INFORMATION

Employer

Employer Phone

Employer Address

Return to Work Coordinator

Phone

Supervisor Name

Phone

Department / Work Site

Work Site Address

SPECIAL INSTRUCTIONS FOR AGENCY - SPECIFIC INFORMATION FOR INVESTIGATION

Upload Documents

Maximum file size: 516MB

Name of Representative Authorizing Services: *

BY SUBMITTING THIS FORM TO THE AGENCY, YOU AFFIRMATIVELY AGREE TO THE FOLLOWING: ALL INFORMATION IS CORRECT.

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Stryker Investigation Services

1 (800) 733-1950

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