DeltaGroup - Home of the Original Remote Surveillance Cameras

Rapid Referral

Please use the following form to submit case details.

Required fields are highlighted in RED

Your Contact Information

Claimant Details

Case Details

Workers Comp

Disability

Liability

Auto

Property

Life & Health

Services Requested

To complete request, select service in "Available" box below and drag/drop it to the "Requested" box. If drag/drop is not available due to your browser settings, please use the arrows to the right of "Available" service listing to move service to "Requested" box. Multiple services can be requested in the same referral.

Available

Requested

Days of Surveillance

Any Remote surveillance requires a minimum of 3 days per request

Medical Canvass

Request Form

Basic

$19.00/facility

1 - 10 facilities

TOTAL # OF FACILITIES:

TOTAL COST OF CANVASS:

FD-1

Request Form

Please Answer All Below Questions

1. How and when did you become suspicious?

2. What caused you to believe insurance fraud occurred or may have occurred?

2a. How did you confirm your suspicions?

3. What are the suspected misrepresentation(s)?

4. Describe any pertinent witnesses or documentation to the alleged misrepresentation(s)?

4.A. If there is any surveillance video, describe whether it was taken near the date of medical examinations or depositions, how much video was obtained and how does the video contradict the applicant?

5. Actual dollar amount paid to date:

6. Suspected fraud loss paid to date:

7. If the employee was working while collecting TTD:

7.A. Explain how you can show that the claimant was advised of their obligation to report any other source of income or any change in their earning status while collecting TTD:

7.B. If the applicant was receiving TTD while working for another employer, state the name of the other employer (if known) and whether the other employer was interviewed:

7.C. If interviewed, document the results of the interview and whether payroll records were obtained from the other employer.

8. If denial or past medical or claim history is a factor:

8.A. Describe whether past medical/claim history file(s) were obtained, whether there is any medical/claim history to the same body part and how a denial of past medical/claim history is material to this claim.

9. If malingering may be present:

9.A. Describe any evidence the reporting party may have that contradicts the applicant/claimant’s physical restrictions and how the malingering is material to the claim?

10. Have you included a copy of the first report of injury? YES/NO

Attachments (Documentation, Images, etc. - Files should be less than 50 MBs in size)