CHS

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Surveillance Enquiry (Agents)

This request for ACTIVITIES investigation requires numerous fields to be completed (see fields denoted with an *asterix). 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.

Agent Details

Panel Solicitors are required to use a different form. Access here

Claims Agent *
If Other
Instructing Officer *
Authorising Officer *
Email Address *
Phone
Facsimile
Claim Number *
Liability Status *	Accepted Pending Denied

Job Number *

Purpose of enquiry

Hours authorised

Subject's Details - All details in this section are required

Full Name and Sex *
Address *
Suburb/Town Postcode *	P/C
Phone contact
Date of Birth *	(dd/mm/yy)
Date of Injury *

Is the worker presently undertaking a return to work program? *
	No Yes
If YES, please provide details.

	300 characters left.

Personal characteristics - Provide detail of known physical characteristics that may assist in identification

	300 characters left.

Description of premises - Provide detail of the subjects premises if known

	300 characters left.

Period of enquiry - Provide detail of the times during which observations should be conducted (if known)

	300 characters left.

Provide detail any other information that may assist the investigator.

	300 characters left.

Has a previous investigation been undertaken? *
	No Yes

Please provide details of any significant findings.

	300 characters left.

Methods Instruction

Approved methods
Photographic stills
Written report of activities
Video recordings
Discreet enquiries
Other (please specify)

Type and scope of enquiry - Observations are required at:
	Domestic environment
	Social environment away from home
Other (please specify)

Information Required

Engaged in employment
Engaged in strenuous activity
Gardening
Shopping
Driving

Employer Details

Employer *
Employer Contact
Employer Phone

Additional Information

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

Misrepresenting disability

Malingering

Employed or seeking employment

Alleging excessive disability

Alleged fraudulent activity

Other (please spcify)

Start date for enquiries

Date report required

Supporting Document Attachment. FILE SIZE MUST BE LESS THAN 2 MEGABYTES..

Alternatively you can send CHS an email with the attachment after submitting this form, or post a hard copy of the document.

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

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