ALOHA INVESTIGATIONS    
         ACTIVITY CHECK CASE ASSIGNMENT FORM
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
Claim Number
Your Name
Title
Your Company Name
Your Telephone Number
Your Fax Number
Cover Page Needed?
Completion Deadline
Your Co. Address
Claimant Information
Name
Address
Telephone
 Date of Birth
Social Security Number
Occupation/Job Title
Is Claimant Still Working?
 Physical description of Claimant
Claimant's Marital Status / Living Arrangements
Other Distinctive Features / Characteristics (Eyeglasses, Facial
Hair, Hair Length, Gait, Physique, Typical Attire Worn, Etc..)
Injury Information
Date of Injury
Alleged Injury
 How Did Injury Occur?
Location of Where Injury Occurred
Date of Notification
Insured Information
Name of Insured
Address
Telephone #
Contact Person & Telephone Number
If We Should Require Additional Information To Identify Or
Locate The Claimant-Should We Contact The Insured?
YES
 NO
Instructions To The Investigator
Request
2 Hours of Sub-Rosa
Neighborhood Knock Only
 Neighborhood Knock & 2 Hours Sub-Rosa
If Claimant is Active Remain On-Site Conducting Sub-Rosa / Update Examiner At That Same Time
If Claimant Is Active Perform
Additional Days Of Investigations
My E-Mail Address Is
Other Relevant Information Or  Instructions 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!