Humboldt Investigations and Photocopy

Toll-Free:(800) 858-7741
Direct:(707) 445-4171
Fax:(707) 445-9118
Address:PO Box 2007 Eureka, CA 95502
Claimant Information
First Name: Last Name:
Address: City: State:
Phone: -- Social Security: --
Birth Date:  /  /  Hire Date:  /  / 
Physical Description:
Family Information:
Is claimant married?
Spouse First Name: Spouse Last Name:
Claimants Children?
Names:
Claim Information:
Applicant's Attorney:
Claim # WCAB #:
Date of Employer's knowledge:  /  /  Date of claim knowledge:  /  / 
Employer Information
Company:
Employer Contact Information:
First Name: Last Name
Address: City: State:
Phone: -- Ext.
Alleged Injury/Disability Information
Injury/Disability Information:
Description:
Date Injured:  /  /  Last Med. Eval.:  /  / 
Last Day Worked:  /  /  Date Returned:  /  / 
Has not returned to work: No lost time:
Primary Treating Physician Information:
First Name: Last Name:
Address: City: State:
Phone: -- Ext.
Medical Group: Next Appt:  /  / 
Requested Services
AOE/COE Sub-Rosa Activity Checks Background Process Service
Statements: Claimant Employer Witness
Other:
Request Records: Employment Claim WCAB Court
Police Accident Credit Medical
Research: Past Claims Address History DMV
Employ. History Vital Records WCAB
Double Copy: Investigation Medical Records
Special Instructions:
Adjuster/Attorney: Phone: --
Carrier/Agency:
Email: Fax:
Fax to follow up:
Needed By:  /  /