Disability Claims Assignment Form

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You will have the option to add additional subjects and upload attachments after submitting this form.

CLIENT INFORMATION

* - required fields
Company: * City: *
Toll free: Position: *
Company Case Manager: Assignment Limit:
Case Manager Phone: Company Case File No.:
Case Manager Fax: Defense Council File No.:
Case Manager Email: Policy Holder:
Defense Council: Claim Department: *
Defense Council Phone: Date Assigned: (MM/DD/YYYY)
Province: *
(where investigation will take place)

EMPLOYEE INFORMATION

Gender: * Occupation:
Name: * Employer:
Phys Description: Spouse:
Address Confirmed?: Address:
City/Prov/PC:
Phone Confirmed?: Phone:
DOB: (MM/DD/YYYY) Drivers License:
Vehicles:
Alleged Disability:
Date of Disability: (MM/DD/YYYY) Date Last Worked: (MM/DD/YYYY)
Date Benefit Commenced: (MM/DD/YYYY) Type of Benefit:
Lawyer:

INVESTIGATION REQUIRED

Phone Case Manager: Previous Injury Claims Search:
Surveillance: Daily Telephone Report:
Specific Times: Date to Commence: (MM/DD/YYYY)
Days of Surveillance: (Days) Video Format:
 
Appointments or Assessments: (Add an Appointment)
Date & TimeTypeLocationPractitioner
1
2

OTHER (If not specified above):
 
Additional Information & Specific Instructions: (Claimed activity level, hobbies or recreational activities, children in the household)