Date of this report:
Claimant: NYSIF Case#: -Unit - D/A:
Agency Name: NWI Investigative Group, Inc. Investigation Date:
Person who conducted investigation: Title: Investigator
Agency Investigation No.: NYSIF Investigation No.:
Phone Field By Appointment Preliminary report #: Final report
Eligibility status checks on beneficiary of death benefits.
The purpose of this assignment is to ascertain the continuing eligibility of the captioned beneficiary for the benefits that are being paid biweekly by computer pursuant to Workers' Compensation Board award. We wish to determine if the beneficiary (ies) is/are alive, still eligible for benefits and that checks are being received timely.
Beneficiary Name: Address on request: Phone #:
Address where beneficiary was seen and/or interviewed: If not at address on request, state reason why.
1. Was beneficiary seen in person?
If yes, provide description:
Height
Weight
Race
Eye color
Hair color
Gender
Distinguishing marks
Does the beneficiary look the stated age?
(If no, explain (# 14) and interview 2 sources not related to or living with beneficiary.)
2. Was beneficiary interviewed?
(If no, explain (#14) and interview 2 sources not related to or living with beneficiary.)
3. Did beneficiary present proper photo identification?
If yes, ID type
Number
If no, state reason
What type of non-photo ID did beneficiary present?
ID type
Number
(If no ID was seen, interview 1 source not related to or living with beneficiary.)
4. Has address and/or phone number of record changed?
If yes, provide new address and/or new phone #
5. If the beneficiary is the spouse has (s) he remarried or plans to re-marry?
If yes, provide details
6. Did beneficiary (if remarried) provide a copy of the marriage certificate?
If no, obtain name, address and phone number where marriage certificate can be secured
7. Are there dependent children?
If yes, provide the following information:
Name
SS#
Date of Birth
8. Is dependent attending school?
If yes, provide the following information:
Name, address and phone number of school
9. Is there a Power of Attorney?
If yes, provide details
10. Are checks being received in a timely manner?
If no, explain
11. Secure a signed and dated form DP523B from the beneficiary.
12. Is beneficiary deceased?
If yes, provide details
13. Did informant (if beneficiary deceased) provide a copy of death certificate?
If no, obtain name, address and phone number where death certificate can be secured.
14. Explanation (Why Beneficiary not seen and/or not interviewed.)
Include in source information: Alive? Lives at address? Remarried? Etc.
Source 1: Provide name and address (include apt. no.) and what source said. If name refused, state NAME REFUSED and provide description.
Source 2: Provide name and address (include apt. no.) and what source said. If name refused, state NAME REFUSED and provide description.
15. Did you encounter anything suspicious while conducting this investigation?
If yes, explain
16. Date, time and results of phone calls.
17. Date and results of letters sent.
18. Was photograph of beneficiary secured?
19. List evidence, which is being forwarded to Point Person.
20. Report text: (Limit to items not previously addressed in template questions.)
Approved by: William J. Donnelly
Rev 12/07