Sample Report

      Date of Report:

01-19-05

      Requestor:

National Insurance Company
Attention:  Client
Street Address
City, State  Zip

       Report:
  REFERRAL DATE: INVESTIGATIVE TYPE: DOL:
01-14-05 WC 01-05-05

  CLAIM #: INJURY: INSURED:
0012398-000112b right elbow Employer Name

  CLAIMANT FIRST NAME: MIDDLE: LAST:
Carl  P Benardson

  CURRENT ADDRESS:
1931 West Plum Street
  CITY: STATE: ZIP:
Woonsocket RI 02895
  SSN: DOB: TELEPHONE #
xxx-xx-1234 10-21-69 401-760-1234
  EMPLOYER :
Sample Employer Name, Address, Telephone
OBJECTIVE OF REPORT:
This case was assigned to determine the claimant’s activity level. 
  PICTURE OF CLAIMANT: DESCRIPTION OF CLAIMANT:
The individual believed to be the claimant can be described as a white male, approximately 6’, 160 pounds, short brown hair, facial hair, bearing several tattoos.
  HAS THE CLAIMANT BEEN POSITIVELY IDENTIFIED? Yes No

NOTES: The individual believed to be the claimant was observed leaving the claimant’s residence driving the claimant's registered vehicle and matched the age description of the claimant.

MAKE: GMC

MODEL: Pickup

COLOR: Silver

PLATE: RI Reg.  #12364

NOTE: This vehicle is registered to Jean Rusto of 1301 Russ Hill Ave, North Providence, RI.

PICTURE OF CLAIMANT’S RESIDENCE:
The claimant’s residence located at 1931 West Plum Street in Woonsocket, RI can be described as a medium sized yellow dwelling converted to a three family home with parking in the rear.  The residence is located at the corner of West Plum Street and Baun Avenue.
ACTIVITIES OF THE CLAIMANT:  


ACTIVITIES OF THE CLAIMANT:
On Wednesday January 19, 2005, the individual believed to be the claimant was observed returning to the claimant’s residence after stopping at a convenience store.  He carried a gallon of milk in his right hand, and a bag in his left.   He used his right elbow to quickly push the driver’s side door closed after exiting his vehicle.
The individual was later observed leaving a Lowe’s store.   He then proceeded to load 1 gallon cans of paint into the truck.   He used his right hand/arm without hesitation.
Later that day the individual believed to be the Claimant was observed scraping paint off of the porch area of the claimant's residence.   He moved his right hand in a vigorous back and forth motion.
Later the same day, individual believed to be the claimant was observed speaking with neighbors.   He moved his arms about with fluid motion as he gestured.
 
 
BACKGROUND INVESTIGATION:

A comprehensive background check on the claimant revealed several citations for speeding, operating a vehicle without insurance, and driving without an inspection sticker.  There were no vehicles found to be registered to the claimant.  The claimant’s given phone number 401-222-3333 is listed under the name of P.  Rusto at the claimant’s address.

 
   
 
INVESTIGATIVE SUMMARY:

On Monday, January 17, 2005, surveillance was conducted at the claimant’s residence at 81931 West Plum Street in Woonsocket, RI.  During this investigation, the individual believed to be the claimant was observed and videotaped as he went to bank, convenience store, a veterinarian and to Lowe’s.   Throughout this investigation the individual believed to be the claimant moved without hesitation and displayed no obvious signs of discomfort. 

 
   
 
RECOMMENDATIONS:

Based on the information obtained to date, it is our professional recommendation that surveillance be continued in a further attempt to show continuity of the claimant’s activities. 

 
 
 
 
INVESTIGATIVE REPORT:  Monday, January 17, 2005

 

8:00 a.m. The investigator proceeded to the claimant’s residence at 831 Elm Street in Woonsocket, RI, in an attempt to observe and document the claimant’s activities.   The residence is a medium sized yellow dwelling converted to a three family home with parking in the rear.   The residence is located at the corner of Elm Street and Jennie  Avenue.   A GMC pickup truck, RI Reg.  #12364, registered to Jean Rusto of 1301 Russ Hill Ave, North Providence, RI and a Toyota Camry, RI Reg.  #16784, no information found, were parked at the residence.   There were three mailboxes behind the dwelling.   The claimant’s name was not visible.   One mailbox displayed the name of Leon Benardson, believed to be the claimant’s brother.   (the background check on the claimant showed he has a brother named Leo, AKA Lee)  Construction work was being done around the residence.  
8:30 a.m. Stationary surveillance was conducted with a view of the rear of the residence and the parking area. 
9:30 a.m.

A young female exited the residence and departed in the blue Toyota Camry, RI Reg.  #16784.

11:00 a.m. Discreet investigative efforts successfully placed the claimant within the residence.
12:18 p.m. A male believed to be the claimant departed in the GMC pickup, RI Reg.  #12364.  Mobile surveillance was initiated. 
12:25 p.m. The individual believed to be the claimant arrived at the Dean Bank drive-thru. 
12:34 p.m. The individual departed the drive-thru and mobile surveillance continued.
12:38 p.m. The individual believed to be the claimant arrived at L’il General Store.
12:41 p.m. The individual believed to be the claimant departed the store.  The individual can be described as approximately 6’, 160 pounds, short brown hair, facial hair bearing several tattoos.   The individual believed to be the claimant held a plastic bag in his left hand and a gallon of milk in his right hand.   The individual moved without hesitation.  He entered his vehicle and departed the area.
12:46 p.m. The individual believed to be the claimant arrived back at the residence.   He was observed reaching with his right arm to gather the items he purchased.   He exited the vehicle with the bag in his left hand and the milk and another small white shopping bag in his right hand. 
12:47 p.m. The individual believed to be the claimant used his right elbow to quickly shut the door of the vehicle.  The individual’s right elbow was bent at a slight angle as he carried the milk into the residence.  The individual spoke with a female and was then observed straightening his right arm/elbow and using his left hand to open the door and enter.  Stationary surveillance was resumed. 
2:42 p.m. The individual believed to be the claimant was observed departing the area with a female passenger.  Mobile surveillance was initiated. 
2:45 p.m. The individual believed to be the claimant arrived at a private residence.   This individual remained in the vehicle while the female passenger entered an  apartment.  Moments later the female returned to the vehicle and mobile surveillance continued. 
2:47 p.m. The individual believed to be the claimant returned to the residence.  His right elbow was bent at a 90 degree angle as he spoke with an unidentified female.  The individual believed to be the claimant walked to the door of the residence.  He was then observed looking through some mail with his left hand.   He then was observed opening an envelope, using his right hand and moments later entered the residence. 
2:57 p.m. The individual believed to be the claimant departed with the female again and mobile surveillance was resumed. 
3:06 p.m. The individual believed to be the claimant arrived at Hill Animal Clinic.   He remained in the vehicle smoking a cigarette.   The female passenger exits the vehicle.   
3:10 p.m. Female enters back into the vehicle and the depart the area.   Mobile surveillance continued.
3:16 p.m. The individual believed to be the claimant arrived at Lowe’s Hardware.   The individual was observed sitting in the truck drinking from a cup which he held in his right hand.   He bent his right elbow to lift the cup to his mouth.   Moments later he exits the vehicle, closing the door with his right hand, transferring his keys from his left hand to his right.   The individual was observed swinging both arms at his sides as he walked across the parking lot.  He entered into the store.   The investigator prepared for covert surveillance and followed. 
3:20 p.m. The individual believed to be the claimant was observed placing a few small items into the carriage using his right arm.  The individual appeared to walk up and down an aisles pushing the carriage without any sign of hesitation or discomfort.   Video was obtained of all activities.  The investigator exited the store and continued surveillance from outside. 
3:29 p.m. The individual believed to be the claimant exited the store with his arms swinging back and forth at his sides.   No hesitation was noted.
3:30 p.m. The individual believed to be the claimant held the end of the shopping cart with his right hand, as the female pushed it to the vehicle.  The individual took two (2) one gallon paint cans from the carriage and placed them into the back of the pickup truck.   He carried one in each hand.  He was observed swinging his right arm up and over the truck bed as he placed the cans within.  The individual then turned around and secured another one gallon paint can using his right hand and placed it into the vehicle.  He then proceeded to pick up a box and placed it in the truck.   He repeated this motion one more time.   The female then returned the cart.   The individual was then observed bending his right elbow as he took his keys from his right pants pocket.   He then lifted his right arm to shoulder level bending his elbow at a 90 degree angle before entering into the truck. 
3:38 p.m. The individual and female returned to the residence.  The investigator drove by and secured a surveillance position.
3:53 p.m. During a drive-by of the residence, the individual believed to be the claimant was observed on a ladder by the front door area.   He was seen scraping the roof of his porch aggressively, using his right hand.   He did in a repetitive motion. 
3:54 p.m. The individual was then observed dropping his right arm down and then thrusting his right arm forward in a quick motion.   He continued to scrape with his right hand above his head, using a vigorous motion.   He then switched to scrape with his left hand and then again back to his right. 
3:55 p.m. The individual got down off the ladder.
3:58 p.m. The individual bent down to the ground.  View was somewhat obstructed by a slight rise in the road.  No on-street parking hampered efforts to secure a closer surveillance position. 
4:00 p.m. The individual believed to be the claimant was observed holding a long wooden plank in his left hand and wiping it down using his right hand.  His movements were quick and fluid. 
4:01 p.m. The individual entered into the residence.
4:02 p.m. The individual exited holding a cup in his right hand, with his right elbow bent as he drank.
4:04 p.m. The individual moved his right arm with quick motions as he spoke with the female on the porch.  The individual believed to be the claimant then sat down and appeared to be looking around the area in a somewhat suspicious manner.   At this time the investigator elected to depart the area temporarily as to preserve the integrity of the case. 
4:26 p.m. The investigator arrived back at the residence, and observed the individual standing in front of the residence with his arms folded at his chest while speaking with an older couple.  The individual believed to be the claimant gestured with his arms and shook his head, then placed his arms by his side.  He then threw a crumpled piece of paper using his right hand, elbow bent at mid-waist.   He placed his right hand on his hip, elbow slightly bent then sat on the porch ledge. 
4:28 p.m. The individual then stood up with his arms folded at his lower chest.   He turned toward the porch and walked over with the older couple. 
4:29 p.m. The individual then was observed waving both his arms in the air before letting them fall at his sides.   He then proceeded to place them on his waist as he spoke with the couple.  He lifted his right arm to chest level stretched out in front of him with his elbow straight, quickly bending his right elbow in at a 90 degree angle to his waist.  The individual brought his hands to his chest bending both elbows and jerks his body forward in two quick motions.  He then released his arms out straight by his.  He continued to move both arms in the aforementioned gestures as he continued to speak with the couple.  The individual then reached for his drink with his right hand, switched it to his left and placed his right hand into his pants pocket. 
4:32 p.m. The individual waved his right am around while speaking.  Surveillance position was relocated at this time due to heavy traffic. 
4:39 p.m. The couple departed.  The individual stood in front of the porch and bent down to pick up a piece of wood with his left hand before walking out of view. 
4:45 p.m The individual believed to be the claimant was observed picking up items on the porch with both hands. 
4:47 p.m The female seen previously was observed helping the individual fold a blanket.  He then walked away.
4:48 p.m The individual came back to the porch and was observed using a push broom with his right arm.  He stopped to pick up something from the floor and walked into the residence. 
4:49 p.m. The individual believed to be the claimant came back outside and was observed replacing yellow tape across the porch, tying it to the railings using both hands.  He then entered the residence with the female. 
5:12 p.m. The individual believed to be the claimant was observed on the porch smoking a cigarette, bending his right hand and elbow towards his mouth several times. 
5:19 p.m. The individual entered the residence.
5:30 p.m. The individual believed to be the claimant remained inside the residence.  Surveillance was concluded at this time and the investigator departed the area.
 
   

END OF REPORT

Reporting Investigator: CV

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Please note:  This is an actual report with names, addresses and all other private information altered to protect the interested parties.

 

 
 

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