chs

Instructions

These statements/questions are designed as a guide to request surveillance and are not exclusive.

Surveillance should not extend beyond 15 hours. To extend or recommence surveillance, the panel firm partner is to re-authorise on a new completed surveillance form.

For more information see, Policy No 7, Investigations.

Panel Firm

1. Complete sections 1 - 11.
2. Add or attach any necessary details on this form or in a separate letter.
3. Give sections 1 - 11 of this form to the PI and retain section 12. Keep a copy of this form in your file.
4. At the time of the instruction.
   • Forward copy of section 1 - 11 to Agent for recording and job allocation number.
   • Panel firm is to enter allocation number in section 1
5. On receipt of PI report
   • Complete form including sections 2, 5 and 12. Retain section 12
   • Send to Agent PI report, PI invoice, Payment Authorisation and fully completed sections 1 - 11
6. If this form is completed for surveillance beyond 15 hours, the job allocation will be the same and Panel Firm enters allocation number in Section 1.

Private Investigator (PI)

1. Carry out the surveillance as requested, in strict compliance with relevant requirements and Code of Practice. (See also Surveillance Guidelines)
2. Refer to the Panel solicitor if you have any queries.
3. If after 7 hours the claimant has not been sighted or you are unable to establish identification, contact Panel solicitor
4. Provide the completed report, any associated materials and invoice for services provided to the Panel Solicitor.

1. Panel Firm and authorisation by partner

Firm name *	Select Abbott Stillman and Wilson Herbert Geer and Rundle Lander and Rogers Mills Oakley TAC Law Wisewoulds Other
Firm Code
Authorising Partner *
Date Issued
Signature
Name of Panel Solicitor *
Email Address *
Phone *
Facsimile
MAIM *
Claim Number *
Authorised Agent *	Select AAI CAM CGU QBE GBS GIO NZI
Job Allocation Number *
Date Authorised
Authorised by

2. Type and timing of enquiry

Surveillance
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

4. Private Investigator

Name of PI firm	CHS
Provider	153249 1
Phone	9894 1940
Fax	9877 3673
Email	info@chsaustralia.com
5. Period and Scope
Surveillance Period
	300  characters left.
Start date
End date
Activity hours allocated
Activity hours conducted
Inactivity Hours Conducted

6. Attached documents

7. Collection Methods

Methods by which information is to be collected, e.g.:

8. Type and scope of information

Surveillance is to be:

9. Nature & details of injury

10. Purpose of surveillance

Purpose of enquiry - We have reason to believe that the claimant may be:

11. Alternative investigation

Alternative investigations that have been considered / undertaken.

This request for ACTIVITIES 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 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