Control #: Our File #: Re-Open    yes    no     Adjuster Name: Company: Address: City: State: Zip: Phone: x Email: Fax: Claim #:     Updates    Daily    Weekly    None Format    VHS    CD    Voice/Email     Neighborhood Canvass/Activity Canvass    yes    no Civil    yes    no Criminal    yes    no WC    yes    no     Recorded Statement Telephonic    yes    no In-Person    yes    no Transcribed    yes    no     Today's Date: Date of Loss: Claim Type Budget:     Insured: Address: City: State: Zip: Contact: Phone:     Subject's Name: Nickname/Alias: SSN: Address: City: State: Zip: DOB: Phone: Sex: Race: Hair Color: Height: Weight: Eye Color: Add'l Description: Vehicles (Lic/Description):    Single    Married Spouse/Partner Name(s): Dependents/Ages:     Alleged Injury: Restrictions: TTD:    yes    no     Current Employer: Address: City: State: Zip: Phone: Occupation: Shift Work:    yes    no Hours:     Sub. Represented:    yes    no Attorney's Name: Def. Attny Name: Trial/Hearing Date:     Medical/Rehab Providers/Appointments:   Special Instructions: