Download the PDF Referral Form or
use the on line form!

Your Information
Claimant: Claim #:
Street Address: Phone #:
City/State/Zip: Fax #:
Is Claimant Represented by Counsel?
Yes No		 Claimant's Attorney:
Occupation: Social Security #:
Employer: Birthdate:
Employer Address: Hire Date:
Contact Person: Phone #:

Injury/Illness Details
Date & Time of Injury or Illness: Date & Time Injury/Illness Reported:
Location Where Injury Took Place:
Specific Injuries, Illness or Complaints:
Complete Description of Injury/Illness:

Services Requested
Please check all that apply ...
Type of Investigation Interviews Background Records/Searches
AOE/COE     Claimant Medical Releases
Statement [only]     Supervisors WCAB Records
Background     Witnesses Court Records
Surveillance Days     Coworkers Police Records
Activity Check Days     Third Party Personnel Records
Other     Doctors Employment Background
Wage Records
Social Security Search
DMV Search
Other
Please Explain If You Checked Other And Enter Any Additional Remarks Here:

Client Information
Client: Phone #:
Street Address: Fax #:
City/State/Zip:
Examiner: E-Mail:
Date Assigned: Date Due:
Defense Attorney: Phone #:
Street Address: Fax #:
City/State/Zip:

Electronic Signature
Your electronic signature below serves as acknowledgement that this is a sincere inquiry, and that all information provided is true, correct and complete.  To complete this form, please provide authorized electronic signature below by typing your name in the box, then submit the form.
Thank you for filling out our Referral Form. We will be in contact with you soon to address your specific needs, and look forward to working with you or helping you in whatever way we can.




 


PO Box 2072 Salinas, California 93902
Phone: 831-422-6671
Toll Free: 1-800-607-8839
Fax: 1-888-800-8799

Copyright 2007 · GY Investigations ·
All rights Reserved
   

 
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