Medical Canvas

Objectives
Specifically how can we help you with this claim, and what do you want to get accomplished through our investigation?
Are there any Red Flags on this case?
Additional Comments

Client Address
Street Address Address Line 2 City State ZIP Code
Employer Name*
Employer Contact
Ok to Contact Employer
- Yes
- No
Employer Phone
Employer Address
Street Address Address Line 2 City State ZIP Code
Defense Firm
Attorney Name
Attorney Phone Phone
Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Claimant D.O.B.*
Claimant Social Security Number*
Claimant Address*
Street Address Address Line 2 City State ZIP Code
Claimant Phone
Gender*
Race
Height
Weight

In Pounds
Hair Color
Drivers License Number
Vehicle Description
(If known)
Occupation
Injury
Date of Injury
MM slash DD slash YYYY
Date of Knowledge
MM slash DD slash YYYY
Restrictions
On Modified Duty
- Yes
- No
Work Schedule
Is the claimant represented by an attorney?
- Yes
- No
Has the Deposition been taken?
- Yes
- No
Date of Deposition
MM slash DD slash YYYY
Prior Surveillance Conducted?
- Yes
- No
Are there any other characteristics about the claimant that might help us in our investigation?