APEX Investigation

Referral Form

Services Requested: Select One Sub Rosa AOE / COE Background Disability Management Investigation Subrogation Recorded Statement SIU – Wkrs. Comp Liability Investigation Auto Theft Investigation Due Date: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2004 2005 2006 2007 2008 2009 2010 2011 RUSH

AOE / COE Interview: (check all that apply) Claimant Medical Auth. WCAB Search Witnesses Employer Medical Rec. Personnel Rec. Other

Background: (check all that apply) Bankruptcy Skip Trace Police Report Civil Search WCAB Search Criminal Search

Client Information Claim Number Employer Claims Examiner Emp. Address Company Emp. Contact Address Employer Phone Address2 Defense Counsel City / St / Zip AZ CA NM NV OR WA other Attorney Name Phone Address Email City / St / Zip AZ CA NM NV OR WA OTHER Copy to Counsel Yes     No Attorney Phone

Claimant Information Claimant Date of Birth Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Address     Address 2 DL# City / St / Zip AZ CA NM NV OR WA other Represented Yes No Phone Date of Injury Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Height Feet 3 4 5 6 7 Inches 0 1 2 3 4 5 6 7 8 9 10 11 Weight Hair Please Select One Auburn Bald Black Blond Brown Dk. Brown Brown & Grey Dyed Reddish Grey Red Sandy Blond Shaved Salt & Pepper White Gender Select One Male Female Race Please Select One Asian Asian Indian African American Caucasian Eastern Indian Eastern European Hispanic Laotian Middle Eastern Western European Japanese Korean Portugese Vietnamese Injury Occupation Restrictions

Prior Surveillance Conducted?     Yes     No Deposition Taken?     Yes     No Upcoming Calendar Dates?

Physician Information Claimant DQME Medical Group Doctor Address Phone City / St / Zip AZ CA NM NV OR WA other Appt. Date Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2003 2004 2005 2006 2007 2008 2009 2010 Appt. Time 01 02 03 04 05 06 07 08 09 10 11 12 : 00 05 10 15 20 25 30 35 40 45 50 55 A.M. P.M.

Investigation Instructions Number of Days Please Select One 1 2 3 4 5 6 7 8 9 10 Objectives / Comments (Please provide any additional information)