INVESTIGATION REQUEST FORM * required field(s)

Claim #:   Date of Referral:   
SIU #:   Due Date:  *   


Client's Contact Information
Last Name:  *  First Name:  * 
Company:  * 
Address:  * 
Address (cont):  
City:  *   
State:  *  Zip Code:  *   
Phone Number:  * 
(example: 456-332-5433)
Alt Phone Number:  
(example: 456-332-5433)
E-Mail Address: *  Fax Number: 
(example: 456-332-5433)

Type of Assignment (check all that apply)*
Surveillance AOE/COE
Claim Investigation FMLA and Employment Benefits Abuse
In Person Recorded Statement Medical Insurance/Malpractice
Telephonic Recorded Statement Personal Injury
Wellness Check Database Research
Activity Check Background Check
Neighborhood Canvassing Court Records Check
Locate Individuals/Witnesses MVD Inquiries
If other type, specify here:

Insured / Additional Information
Name of Insured: 
Contact: 
Phone: 
(example: 456-332-5433)

Has file been previously investigated: 
Is the report available: 
    Nathe & Nathe to contact Insured: 
Type of Loss: 
Additional Information or Instructions: 
Client's Defense Attorney's Name : 
Attorney's Phone Number :  (example: 456-332-5433)

Subject Information
Last Name:* 
First Name:* 
Middle Name: 
Alias(s): 
Address:* 
Address (cont): 
City:*   
State:*  Zip Code: 
Phone Number:  (example: 456-332-5433)
Driver's License #: 
Alt Phone Number:  (example: 456-332-5433)
Vehicles Owned: 
Social Security #:  Hobbies: 
 
Date of Birth:* 
 Month Day Year

Physical Description & Family Information
Sex:  Race: 
Height:  Weight: 
Hair Color:  Eye Color: 
Glasses: 
Additonal Description: 
(facial hair, scars, tatoos, etc.)
Marital Status:  Spouse's Name: 
Family Details:  Children: 

Incident/Claim Information
 
Date of Incident:* 
 Month Day Year
Type of Injury: 
Occupation at Time of Injury: 
Current Occupation: 
How Incident Occurred: 
Alleged Injuries: 
Physical Restrictions: 
Subjective Complaints: 
Miscellaneous Information
(reason for investigation, vehicles owned, special instructions, etc.): 
 
Legal Information
Is File Litigated: 
Subject's Attorney's Name: 
Subject's Attorney's Phone: 
(example: 456-332-5433)
Known Legal/Court Appointments
(depositions,hearings,trials.etc.): 
 
Treating Doctor Information
Treating Doctor: 
Address: 
Address (cont): 
City:   
State:  Zip Code:   
Phone Number:  (example: 456-332-5433)
Misc Info: 
Known Medical Appointments: