(Full investigation sent to Horizon Adjusters and 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