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

Excaliber Investigations - Request for Investigation - Workers' Compensation Online Form

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

Requestor:

Phone:

E-mail:

Company:

File #:

Investigation Desired:

AOE/COE Investigation

Special Investigation

Scene Investigation

Activities Check

Subrogation

Service of Process

Photocopy Records

Date of Injury:

Injury:

Subject's Name:

DOB:

Residence:

Phone:

Social Security #:

WCAB #:

Business Address:

Phone:

Contact Person:

Defendant's Attorney:

Plaintiff's Attorney:

Attending Physician:

Surveillance at:

Number of Days:

Weekday

0 1 2 3 4 5

Weekend

0 1 2

DL #:

Vehicle License #:

Description:

Height:

Weight:

Complexion:

Hair:

Eyes:

Instructions

.                     Interview                     .

.                          Check                          .

.                             Secure                             .

Claimant

Employer

Employment

AOE/COE

Personnel File

Medical Records

Witness

Doctor

Past Medical

WCAB Record

Wage Records

Police Records

Third Party

Claim ATTY

Subrogation

Dependency

Death Certificate

Marriage License

Police

Intoxication

Serious and Willful

Birth Certificate

Divorce Decree

Independent Contractor

Medical Authorization

Decision Date:

Other:

You need Java to see this applet.