Requesting Company |
Req_Company |
Requestor Name |
Req_Name |
Requestor Address |
Req_Address |
Requestor Telephone |
Req_Telephone |
Requestor Email |
Req_Email |
File Number |
File_Number |
Type of Investigation |
Invest_Type
|
How Much Investigation |
amounthowmuch
|
Claimant's Last Name |
Subject_Last
|
Claimant's First Name |
Subject_First
|
Address |
Subject_Address
|
Social Security Number |
Subject_SS
|
Date of Birth |
Subject_DOB
|
Telephone Number |
Subject_Tel
|
Date of Loss |
Date_Of_Loss
|
Injury Type |
Injury_Type
|
Insured |
Insured
|
Claimant Represented |
Claimant_Rep
|
Pending Medical Exams |
Pending_Exams
|
Date/Time of Exam |
Date_Exam
|
Location of Exam |
Location_Exam
|
Doctor or Exam Company |
Exam_Doc
|
Scheduled Hearings |
Hearings
|
Hearing Date/Time/Location |
Hearing_Info
|
Additional Notes |
Notes
|
Confirm Order By |
Verify
|
|