(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

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