ALOHA INVESTIGATIONS
AOE/COE CASE ASSIGNMENT FORM
Please Fill-Out The Information Which Applies To Your Case. If Pressed For Time Complete Your Contact Information &
We Will Call You At Your Convenience To Obtain The Remainder Of The Information.
Mahalo!
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Today's Date
Claim Number
Your Name
Title
Claims Adjuster
Claims Examiner
Claims Manager / Supervisor
Assistant
Support Staff
SIU Staff
Other
Your Company Name
Your Tele. Number
Your Fax Number
Cover Page Needed?
Yes
No
Completion Deadline
Your Co. Address
Claimant Information
Name
Address
Telephone
Date of Birth
Social Security Number
Occupation/Job Title
Is Claimant Still Working?
Yes
No
Unknown
Injury Information
Alleged Injury
Date of Injury
How Did Injury Occur?
Location of Where Injury Occurred
Date of Notification
Insured Information
Name of Insured
Address
Telephone #
Contact Person & Telephone Number
Other Information / Instructions Regarding Contact With Insured
Instructions To The Investigator
Supervisor
Witnesses
Claimant
Please Interview:
Other-Specify
Coworkers
Please Secure the Following
Medical Authorization Form
Personnel Records at Insured
Medical Records
Court Records / Public Records
Secure Evidence, Equipment, Other Item
Comments or Other Directions-Specify In Box
Thank You For Assigning Your Case To Aloha.
We Will Contact You By E-Mail Or Telephone To
Confirm Reception Of The Case.
Mahalo!