(Full investigation sent to Everglades Claims Investigations)
*Company Name
(Claims Unit:)
*Claims Unit Address
*Examiner Name
*Examiner Phone (include area code): ( )
*Examiner E-mail
Assignment sheet:
*Company Claim Number
*Date of Loss (mm/dd/yyyy) / /
*Insured Employer
*Claimant
*Claimant Address
*Claimant Phone (include area code): ( )
Statements from:
Statement 1
Statement 2
Statement 3
Additional Requests and/or Comments