AOE/COE ASSIGNMENT  From  Company  Phone #  Ext  Claim #  Insured/Employer  Contact  Phone  Address  City  State  Zip  Claimant  AKA  Phone  Address  City  State/Zip  Occupation  DOB  SSN  Sex M   F  Supervisor  Dept. Manager  Date of Injury:  Time:  Location:  Facts  Injury(s) ISSUES AOE/COE (See Remarks) Subrogation Serious & Willful Apportionment Dependency Going & Coming INTERVIEW Claimant Witnesses Supervisor Employer Third Party Other: SECURE Personnel Records Wage Statement Medical Authorization Medical Records Birth/Death Certificate Other: Remarks  Date of Assignment:  90-Day Discovery Period Ends: