(Task claims assignment sheet sent to Everglades Claims Investigations)
*Company Name
(Claims Department)
*Company Address
*Company Claim Number
*Date of Loss (mm/dd/yyyy) / /
*Insured Employer
*Insured Employer Location Number
*Insured Employer Address
*Insured Employer Phone (include area code): ( )
*Claimant
*Claimant Address
*Claimant Phone (include area code): ( )
*Examiner Name
*Examiner Ext.
*Examiner E-mail
Limited Investigation to include statements of:
Statement 1
Statement 2
Statement 3
Additional Requests and/or Comments