Filomeo Investigative Services
PI21087
PO Box 6614, Eureka, CA 95502
(707) 445-1004 / (707) 442-3536 Fax

INVESTIGATION/ASSIGNMENT REFERRAL

*Date of Referral:
Due Date:
 
* Your Name/Company:
 
* Phone:
 
Case/Claim # :
 
DOI/DOL:
 
* Claimant:
 
Phone:
 
Address
 
Sex:
 
Date of Birth:
        SSN
Occupation / Job Title:
 
* Employer:
 
Address:
 
Contact Person:
 
Telephone:
 
*Email:
 
Description of Injury / Loss / Investigation and Assignment Instructions:
 
       
Interview Issues Secure
AOE/COE Medical Authorization
Employer Serious and Willfull Medical Records
Supervisor SIU (Fraud) WCAB Records
Witnesses Subrogation Psyche Release
Coworkers Apportionment Coroner's Report
Other EEOC Employer Records
Recorded Statements Post Employ Claim Police Report
Transcribe Statements Delayed Reporting Civil/Criminal Court Records
Surveillance No. of Days Activity Check No. of Days