(800) 944-2748
info@arguswest.com
Today’s Date:
Due Date:
Your Contact Name:
Company:
Program Code:
Address:
City:
State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Zip:
Email:
Telephone:
Fax:
Defense Attorney:
L/O Name:
WCAB No:
Insured/Employer:
Contact:
May we contact? YesNo
Claimant/Subject:
Claim No:
Addl. Info:
SSN:
DOB:
CDL:
Sex:
Race:
Ht:
Wt:
Hair Color/Style:
Occupation:
DOH:
DOI:
LDW:
RTW:
Injury:
Limitations:
Claimant Working at Insured Y/N? YesNo
On Modified Duty Y/N? YesNo
If Claimant TTD, till when?
90 Day Delay Date is:
Surveillance
AOE/COESubrogationLiabilityMedical CanvassSocial Media InvestigationBackground CheckSIU/FraudOther
Insured (Auto)ClaimantSupervisorCo-WorkersWitnessesThird Party
Personnel RecordsMedical Records ReleaseMedical RecordsWage StatementPolice ReportPhotos (Explain)
Special Instructions: Please upload file: