Employment Practices Assignment Form

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Location of Assignment:	other:
Contact Information
First Name:
Last Name:
Company:
Address:
City:
State:
Zip:
Tel:
Fax:
Email:
Your Claim #:
Preferred Form of Reports / Communications:
Investigation Information
Statement Taken by ER: If yes, attach statement.	Yes No
Investigation by ER: If yes, attach any writings.	Yes No
Employer / Insured Information
Employer / Insured:
Insured Contact:
Insured's Address:
City:
State:
Zip:
Phone:
Fax:
Employee Information
Employee:
Employee's Address:
City:
State:
Zip:
Phone:
Fax:
Age:
Employee's Attorney: If none, please indicate.
Address:
City:
State:
Zip:
Phone:
Fax:
Witness Information
Name:
Address:
City:
State:
Zip:
Phone:
Loss Information
Loss Date:
Time:
Alleged Harasser:
Allegations:
Facts:
Other Witnesses:
Special Instructions / Comments:
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