Southern California
Office: (562) 697-6747
Fax: (562) 694-8530
info@excaliberinvestigations.com
www.excaliberinvestgations.com
 Excaliber Investigations
- Request for Investigation -
Life and Health Online Form
 Northern California
Office: (209) 835-6413
Fax: (562) 694-8530
info@excaliberinvestigations.com
www.excaliberinvestgations.com
Requestor:
 Phone:
 E-mail:
Company:
 Claim #:
Policy #:
 Amount of Insurance:
_______________________________________________________________________________________________
SPECIAL CONTESTABLE DEATH CLAIM
 SPECIAL ACCIDENTAL DEATH CLAIM
Insured's Name:
 DOB:
Last Address:
Social Security #:
 Address when insured:
Employer:
 Address:
Date of Issue:
 Date of Reinstatement:
Beneficiary's Name:
 Relationship:
Address:
Date of Death:
 Place of Death:
Cause of Death:
If Accident - Date:
 Place of Accident:
Primary Physician:
 Address:
Other Physicians:
 Address:
Address:
Hospitals:
 Address:
Address:
Obtain reports or copies of items checked below for details of death:
Coroner
 Autopsy
 Police/Highway Patrol
and/or Sheriff Report
 Newspaper Articles
Blood Alcohol
 Toxicology
 Any Suicide Notes
Obtain hospital records (Include History and Summary)
 Obtain copies of records from physicians
Copies of payroll record
 Copies of tax records
Check health history from:
 to:
 .                  Contact doctors and hospitals for
authorizations, signed statements, and copies of hospital records. Follow up on all medical leads. Obtain all doctor's
statements and/or hospital records to cover the period of time shown.
Obtain the following information:
By interviewing:
 1.
 2.
3.
 4.
Surveillance at:
 Number of Days:
 Weekday
 Weekend
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