ALOHA INVESTIGATIONS
Please Fill-Out The Areas Which Apply To Your Case. If Pressed For Time Provide Your Contact
Information & We Will Call You At Your Convenience To Obtain The Remainder Of The Information.
Mahalo!
Today's Date
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Claim Number
Your Name
Claims Adjuster
Claims Examiner
Claims Manager / Supervisor
Assistant
Support Staff
SIU Staff
Other
Title
Your Company Name
Your Telephone Number
Your Co. Address
Claimant Information
Name
Address
Telephone
Date of Birth
Social Security Number
Occupation/Job Title
Is Claimant Still Working?
Yes
No
Unknown
Physical description of Claimant-if known:
Claimant's Marital Status / Living Arrangements
Other Distinctive Features / Characteristics (Eyeglasses, Facial Hair, Hair Length, Gait,
Physique, Typical Attire Worn, Etc..)
Injury Information
Alleged Injury
Date of Injury
Insured Information
Name of Insured
Address
Contact Person & Telephone Number
Information Concerning Other Employment / Concurrent Employment-If Applicable:
If We Should Require Additional Information To Identify Or
Locate The Claimant-Should We Contact The Insured?
NO
YES
Instructions To The Investigator
Request
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
4 hours
6 hours
Days of Surveillance
Specific Days / Dates For Surveillance
Update Examiner :
After Four Hours of On-Site Surveillance
At End of Each Day of Surveillance
Prefer Case Updates Be Made By
E-Mail
Voice Mail Messages
Personal Phone Call
My E-Mail Address Is
Other Relevant Information Regarding This Assignment
Thank You For Assigning Your Case To Aloha. We Will Contact You By E-Mail Or
Telephone To Confirm Reception Of The Case.
Mahalo!
VIDEO SURVEILLANCE CASE ASSIGNMENT FORM