DMI - Investigations

Complete the form below for a Workman's Compensation Investigation request.  A representive of the DMI agency will be in contact with you within 24 hours.
Your information is kept in the utmost privacy.
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Requestor's Name
Company Name
Street Address
Mailing Address
City
State
Zip
Daytime Phone
Email
Examiner
Examiner's Phone
Claim Number
Case Title
Employer Information
Employer
Address
City
State
Zip
Contact Person
Phone
Employee Information
Name
Address
City
State
Zip
Phone
Prior Address
Prior City
Prior State
Prior Zip
Job Description
Social Security Number
Hire Date
Injury Date
Date of Birth:
Hair Color
Eye Color
Height
Weight
Describe Injury:
Restrictions:
Applicants Attorney
Attorney Phone
Investigation Type: 
Other:
Interview/Statement:
Other:
Obtain:
Other:
Call Client Prior to Initiating Investigation / Records Retrieval
Complete Investigation/Deliver Records by (date):
Additional Comments