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Legal Panel Firm Request for Circumstance Investigation


Instructions

These statements/questions are designed as a guide to engaging a private investigator (PI).
These are guidelines only and are not exclusive.

The purpose of this request is to investigate and obtain evidence so as to provide legal advice to the VWA and its authorised agent and the employer in relation to active or potential litigation. As such, legal privilege applies.

Panel Firm

  1. Tick the checkboxes to indicate to the PI which points are to be obtained, investigated and / or reported.
  2. Add any necessary details on this form or in a separate letter.
  3. Give a copy of this form to the PI firm and keep a copy in your file.
  4. At the time of instruction, forward a copy to Agent who will advise of job allocation number. Panel firm is to enter allocation number in section 1.
  5. On satisfactory completion of investigation, complete part 2. Forward PI report, PI invoice, Payment Authorisation and completed form form to Agent.

Private Investigator (PI)

In accordance with the Code of Practice, obtain, investigate and / or report on, the requested points. If you are unclear, liaise with the Panel solicitor instructing you. Provide completed report, any associated materials and invoice for service provided to Panel Solicitor.

When to use this form

Panel firms should use this form to request investigation for claims. This form can be used to request an inquiry on the worker, employer or others who might have information which will help in the assessment of the claim.

If surveillance is required, complete the Surveillance Form for PI

1. Panel Firm

Firm name *
Firm Code
Panel Solicitor *
Email Address *
Phone
Facsimile
LAID
Claim Number *
Authorised Agent*
   
Job Allocation Number *
Date Authorised
Authorised by *

2. Type and timing of enquiry

Circumstances
Other
Enquiry Timeliness Urgent Not Urgent
   
Reason for Urgency
  300  characters left.
   
Date Report Required
Date Extension Requested
   
Reason for Extension
  300  characters left.
   
New date report required
Date Report received
   

3. Claim ID

Subject of this enquiry Worker Employer Other
Name
 
Address
Suburb/Town P/C
Phone contact
Date of Birth (dd/mm/yy)
Claim Status Accepted Pending Denied
   
Injury / Condition details
  300  characters left.
   
Occupation and Employer when injured
  300  characters left.
   
Date ceased work
Current work / employer
   

4. Private Investigator

Name of PI firm CYGNUS HIGGINS SHAW
Provider 153249 1
Phone 9894 1940
Fax 9877 3673
Email info@chsaustralia.com

5. Attached documents

Claims Form
Employer's Form
Medical Certificate(s)
Affidavits
Supporting doc: Requesting and
Appraisal for appointment of PI
Survelliance Guidelines
   
Other relevant documents
  300  characters left.
   
Previous investigations and
significant results / issues
  300  characters left.
   
Previous surveillance and
significant results / issues
  300  characters left.

6. Circumstances and Liability - Inc recovery potential

Any incident report, statement or diary entry obtained or made by the employer or witness
   
A copy of any entry in the Register of Injuries, first aid records or injury book
   
Either before or after the injury / incident was the relevant system or work the subject of investigation or assessment by the employer?
   
If report was made, provide a copy.
   
Documents setting out the system of work or relevant procedures.
   
Was the incident or injury reported to or investigated by the VWA or by any other person or body?
   
Were any changes made to the system of work (or instructions given to workers) after the incident/injury reported by the worker?
  • What changes?
  • When were they made or given?
  • Why were they made or given?
  • Provide copies of any written documentation.
    • Did the worker contribute in any way to the injury?
       
    If procedures, work practices or instructions were not followed, provide as much detail as possible, including copies of relevant work procedures, training records etc.
       
    Did any other person or organisation contribute in any way to the injury?
    If YES:
  • How?
  • What is their name and location?
    		•
       
    Obtain signed statements from all appropriate witnesses dealing with what happened, including a full description of the place, time, equipment and systems involved.
       
    Obtain photographs or video if they help explain what happened.
    If relevant, fully describe relevant measurements, weights, distances, frequency etc.
       
    Why it happened, including details of instructions, work procedures etc.
    Changes to the system of work, if any, after the incident/injury.
       
    Was a motor vehicle, train, tram or rolling stock involved in the accident?
    If YES:
  • How?
    		•
       
    If the injury arose out of the use of a motor vehicle, determine
  • The make and model
  • Whether it was registered either at the time of the accident or previously

    • If So:
  • What is the registration number and state of registration?
  • What are the details of the registered owner and driver at the time of the accident?
  • If appropriate, also provide a copy of the relevant registration and vehicle service documents.
    		•
       
    Other inquiries about circumstances, liability recovery include:  
     
    300  characters left.  

    7. Worker's profile

    A full copy of the worker's employment and personnel file including all wage records, leave records, counseling, disciplinary action, etc.
    Any employment application or worker's CV.
    Any pre-employment medical exam report or questionnaire
    A copy of all medical certificates (ordinary or otherwise) submitted by the worker prior to or since the injury/incident.
    The worker's qualifications.
    Courses completed by the worker during their employment.
    NOTE: "Wage records" should include all details of all income to the worker including earnings, salaries, wages, fees, commissions, bonuses, pensions, superannuation allowance (whether paid by the employer, or by salary sacrifice) etc. Knowledge of the employer and relevant co-workers etc, about:

  • the worker's hobbies and interests outside employment
    		•
  • any previous injuries, compensation claims, car accidents, etc
  • any relevant past employment and relevant information from past employers
    		•
  • the worker's current financial circumstances
    		•
       
    Other:  
     
    300  characters left.  

    8. RTW / Rehabilitation / Employment

    Describe the worker's pre-injury duties. (if appropriate, video the duties)
       
    Describe fully any RTW duties
       
    Does the employer consider that, but for the injury, the worker would have retired, been retrenched or otherwise ceased work before the age of 65?
  • provide details, statements, supporting statistics. For example, the number of similar workers employed, ages of those workers etc.
    		•
       
    But for the injury, what were the worker's promotional prospects?
  • Over what time frame would promotion have been expected, and to what level?
    		•
       
    Is the worker's ongoing employment secure?
       
    Is a suitable offer of employment available from the employer?
       
    Has the worker's employment been terminated? If YES, provide details of termination
       
    Other types of employment, which might be available in the area where the worker was employed, particularly in rural cases or specific industries
       
    Obtain employment history from past employers
       
    Is the worker self-employed? If YES, provide taxation returns of the worker or his/her business, to ensure accurate calculation of earnings.
       
    All other enquiries :  
     
    300  characters left.  
       

    Please forward a copy of this submission to the following email address:


    9. Employer excess payments

    What are the details of the weekly compensation payments to the worker, direct from the employer, under the employer's excess?
    What are the details of the medical and like expenses paid by the employer, under the employer's excess, direct to:
    they worker, or
    the worker's health professionals?

    This request for CIRCUMSTANCES investigation requires numerous fields to be completed *. Instructions requested electronically will be confirmed by an automated response from CHS to the requesting email address. Any supporting documentation should be sent to CHS either by AUSDOC, normal postal service, or as PDF via email. If you require to view the report as it is compiled via the CHS Secure Access Facility, please ensure that you have a User Name and password. If you do not have a User Name and Password, click here.

    CHS undertakes to conduct all enquiries in accordance with the 'Code of Practice for Private Investigators' as issued by the Victorian WorkCover Authority (effective 1/1/2003).


    *required field