ALOHA INVESTIGATIONS
STATEMENT(S) ONLY
Please Fill-Out Those Areas Which Apply To Your Case & This Request. If Pressed For Time, Fill-Out Your
Contact Information & We Will Call You Later By Telephone & Obtain The Remainder Of The Information.
Mahalo!
Today's Date
April
May
June
July
August
September
October
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Jaunuary
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2006
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2011
Claim Number
Your Name
Title
Claims Adjuster
Claims Examiner
Claims Manager / Supervisor
Assistant
Support Staff
SIU Staff
Other
Your Company Name
Your Telephone Number
Your Fax Number
Yes
No
Completion Deadline
Cover Page Needed?
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 #
Instructions To The Investigator
Supervisor
Witnesses
Claimant
Please Interview:
Other-Specify
Coworkers
Thank You For Assigning Your Case To Aloha. We Will Contact You By
E-Mail Or Telephone To Confirm Reception Of The Case.
Mahalo!