independent claims adjusters, claim managers, insurance temporary service providers, multi-line claims, fire and allied lines, workers compensation, surveillance professionals, Oak Hill Associates, Inc.

Oak Hill Associates, Inc.

Workers Comp Loss Assignment

Report to:		Company:
Email:		Address:
Telephone:		Claim #:
Report via Email		Report via Regular Mail

Narrative Assignment Instructions
Full Investigation

Instructions for Assignment

Insured Recorded Statement

Determine average weekly wage/TTD

Claimant Recorded Statement

Determine Compensability

Witness Recorded Statement

Photo/Diagram/Measurements of scene

	Digital Photography
	Regular Photography

Complete Index Worksheet

Determine cause of loss

Obtain any Reports

Rule out bodily injury

Canvass for witnesses

Subro Investigation

Obtain Medical History

Other:

Obtain Wage Information

Loss Information

Insured Name:		Policy Number:
Insured Address		Effective Date:
Insured Phone:		Self Insured: Y N
Contact Person:
Date of Loss		Expiration Date:
Employees Name:		Date of Birth:
Home Address:
Home Telephone:
SS Number:
Male	Female	Married Divorced	Single Widow(er)
Date and time of injury or exposure:
Employee average weekly earnings:
Last day worked:		Job Title/occupation:
Location where injury occurred:
How did accident occur:
Nature of injury:
Task being performed at time of injury:
Object or substance responsible for injury:
Have medical services been rendered? Y N		Has employee been hospitalized? Y N
Name and Address of Physician:		Name and Address of Hospital:

Oak Hill Associates, Inc.
2077 Burlington Ave.
Lisle, Illinois 60532-1788
Phone: 630.969.1999
Fax: 630.515.9554

Email: info@OakHillAssoc.com
URL: www.OakHillAssoc.com

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