Case Assignment Form
Investigation Request
Requested by:
Company:
Address first line:
Address second line:
City:
State:
Zip code:
e-mail:
Receive e-mail updates:
No answer
yes
no
e-mail updates, how often?:
Claim No.:
Prior file number:
Carbon copy to:
Telephone:
Facsimile:
Type of Investigation
Surveillance with Video Evidence
Comprehensive Activities check
Basic Activities Check
Alive and Well Check
Locate Investigation
Locate and Process Service
Subrogation / Residency Investigation
Hospital Admission Canvass
In-Person Recorded Statement
Telephonic Recorded Statement
Criminal History Search
Court Record Canvass
Pharmacy Canvass
Automotive Theft Investigation
Claimant Information
Today's date:
Wednesday February 22nd 2012
Type of claim:
Name-Last, First:
Address line one:
Address line two:
City:
State:
Zip code:
Telephone:
Date of birth:
Social Security No.:
Height:
Weight:
Hair:
Sex:
Race:
Uses glasses:
No answer
yes
no
Pending Appts (IME, EUO, PT):
Date Required:
Date of loss:
Type of injury:
Physical restrictions:
Driver's license number:
Vehicle description:
Dependants:
Employer:
May we contact employer:
No answer
yes
no
Employer contact:
Employer telephone:
Prior investigation conducted:
No answer
yes
no
Is claim in Litigation or subject represented by an Attorney?:
No answer
yes
no
Budget (days or dollar amount):
Additional Information
If a video will be produced for you, which format?:
No answer
dvd
vhs
How many copies of the video?:
Additional Information
Please provide all additional information you have which may be pertinent.
Submit Information