Please print this page, fill out the Case Assignment Form below and fax or mail it to us.
Case Assignment Form
DATE: __________________________________________ CLAIM NO: _____________________
REQUESTED BY: ___________________________________________ TEL: ________________
___________________________________________
___________________________________________
INSURED/ ___________________________________________ TEL: ________________
EMPLOYER: ___________________________________________
___________________________________________
CONTACT: ___________________________________________
CLAIMANT: ___________________________________________ TEL: _______________
ADDRESS: ____________________________________________
____________________________________________
HEIGHT: ____________________ WEIGHT: ___________________ DOB: _________________
OCCUPATION: ___________________________________________ SSN: _______________
DATE OF HIRE: __________________________________________
DATE OF INJURY: _____________________________________ INJURY: _________________
DEFENSE: ________________________________________ APPLICANT: ______________
ATTORNEY: ___________________________ ATTORNEY: ______________________________
____________________________ ______________________________
TYPE OF INVESTIGATION:
_____ AOE/COE
_____ COURT
RECORDS
_____ WITNESSES
SEARCH
_____
SUBROGATION
_____ MEDICAL
_____ OTHER
AUTHORIZATION
COMMENTS: ___________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PEREA &
ASSOCIATES
P.O. BOX 14373
FREMONT, CA 94539
FAX: (510) 795-9446