CLIENT INFORMATION Case Manager/Client Contact*
Phone*
Email Address*
Claim Number*
EMPLOYER INFORMATION Company*
Employer Contact*
Address (including suburb)*
CLAIMANT INFORMATION Injured Worker*
Worker's DOB*
Worker's Address*
Suburb/Postcode*
Occupation/Roster*
Date of Injury*
Injury/Restrictions*
Solicitor Engaged, If Any
Description of Worker (include height, weight, build, hair, relationship status, dependents, other features (such as tattoos), vehicle, other premises, and all others that may apply)
SURVEILLANCE INVESTIGATION INSTRUCTIONS Number of Hours
Specific Surveillance Days / Hours to be Conducted?
Objectives/Comments & Additional Instructions
