Referral Form

Tel: (831) 422-6671
Fax: 831 422-4970
Email:gyii@att.net

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About
» About Mr. Yancey
» About GY Investigations
Client Testimonials
Referral Form
Contact

Referral Form

Since 1994, GY Investigations has enjoyed a high success rate in identifying and assisting in Workers' Compensation fraud convictions under California Insurance Code 1871.4. our philosophy is quite simple - we are committed to providing only the very best service to our clients.

Download the PDF Referral Form or complete the online form below.

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
AOE/COE
Statement [only]
Background
Surveillance Days
Activity Check
Other
Interviews
Claimant
Supervisors
Witnesses
Coworkers
Third Party
Doctors
Background Records/Searches
Medical Releases
WCAB Records
Court Records
Police Records
Personnel Records
Employment Background
Wage Records
Social Security Search
DMV Search
Other
Days
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.

GY Investigations and Legal Services, [Est. 1992], is a full-service investigation agency.

GY Investigations. All rights Reserved.
California Lic. # PI 15959
California Lic. # PI 26216
Arizona Lic. PI 1003909

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