Investigation Request - Worldwide Resource, Inc.

Company Name: *

Account Number:

Requester Name: *

Requester Phone: *

Requester FAX:

Requester Email: *

Confirm Email: *

Date: *

Type in date xx/xx/xxxx

File Number(s): *

Date of Loss: *

Type in date xx/xx/xxxx

Date of Issue: *

Type in date xx/xx/xxxx

Type of Investigation: *

Insured/Subject Name: *

Insured/Subject Address:

City

State/Province

Zip/Postal

Country

Date of Birth: *

Type in date xx/xx/xxxx

SSN: *

DL#:

Employer:

Occupation:

Employer Address:

City

State/Province

Zip/Postal

Country

Employer Phone:

Nature of Loss:

Amount of Loss:

Smoking: (Y/N)

Yes

No

Location of Loss:

Beneficiary/NOK/Claimant Name: *

Beneficiary Address:

City

State/Province

Zip/Postal

Country

Beneficiary Phone: *

Attorney:

Attorney Phone:

Source/Medical Provider 1 Name:

Source/Medical Provider 1 Phone:

Source/Medical Provider 1 Address:

Source/Medical Provider 2 Name:

Source/Medical Provider 2 Phone:

Source/Medical Provider 2 Address:

Source/Medical Provider 3 Name:

Source/Medical Provider 3 Phone:

Source/Medical Provider 3 Address:

Comments/Special Instructions: (up to 1000 characters allowed)

Foreign Death Claim Checklist

If necessary, you may download a Foreign Death Claim Checklist by clicking HERE. After completing the form, please attach it below.

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File 1: *

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File 2:

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File 3:

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