Title Page
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Surveillance Report:
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Subject Employee ID #
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Name:
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Profile Picture:
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Eye color:
- Green
- Hazel
- Blue
- Brown
- Gray
- Amber
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Date of birth:
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Address on record:
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Subject last worked at:
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Insurance type:
- OCIP (Owner Controlled Insurance Program)
- CCIP (Contractor Controlled Insurance Program)
- GL (General Liability)
Background information
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Brief summary of the alleged incident/injury:
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Part(s) of body claimed to be affected by the alleged injury:
- Head
- Neck
- Back
- Chest
- Abdomen
- Left shoulder
- Right shoulder
- Left arm
- Right arm
- Left hand
- Right hand
- Pelvis
- Left leg
- Right leg
- Left foot
- Right foot
- Other
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Potential lead(s)
Surveillance
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The address of the subject has been confirmed and is accurate
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Photo of the subject(s) residence
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Purpose of surveillance/investigation(s)
- Reason to believe that the subject is exaggerating their injury
- Reason to believe the subject has faked/staged a work related injury
- Reason to believe subject is malingering
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Please give details of the Investigation ( Example: On Thursday, October 14th, 2021 Investigator 1 and 2 traveled to the ubjects address located at 511 W. 181st st, NY, NY arriving at approximately 10AM. The residence is a 5 story brick building attached to either side with 2 store fronts at the ground level. Building is mixed use area ( heavy commercial) attached to a FDNY Firehouse ( See pictures ) it is located on a 2 way street. Legal parking is non-existant.
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Surveillance summary 01:
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Surveillance summary 02:
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Surveillance summary 03:
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Surveillance summary 04:
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Surveillance summary 05:
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Surveillance summary 06:
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Surveillance summary 07:
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Surveillance summary 08:
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Surveillance summary 09:
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Surveillance summary 10:
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Date of Surveillance:
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Case status update:
