Southern California Office: (562) 697-6747 Fax: (562) 694-8530 info@excaliberinvestigations.com www.excaliberinvestgations.com

Excaliber Investigations - Request for Investigation - Disability Online Form

Northern California Office: (209) 835-6413 Fax: (562) 694-8530 info@excaliberinvestigations.com www.excaliberinvestgations.com

Requestor:

Phone:

E-mail:

Company:

Policy/Claim #:

Type:

Issue Date:

Amount:

Claimant's Name:

DOB:

Residence:

Phone:

Social Security #:

Employer:

Occupation:

Business Address:

Phone:

Date of Disability:

Cause of Disability:

Location of Injury:

Investigation Desired: Please include names/adress of doctors/hospitals, previous addresses, previous employers, and other pertinent information.

Claimant Interview:

Observation

Prior Medical History

Onset and History of Treatment

Daily Activities

Employment

Education/Training/Experience

Sources of Income

Other:

Medical Contact:

Instructions: Photocopy/Interview

1.

2.

3.

Surveillance at:

Number of Days:

Weekday

0 1 2 3 4 5

Weekend

0 1 2

Other:

Comments:

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