INVESTIGATION REQUEST FORM * required field(s)

Claim #:   Date of Referral:   

Client's Contact Information
Last Name:  *  First Name:  * 
Company:  * 
Phone Number:  * 
(example: 456-332-5433)
E-Mail Address: * 

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:

Additional Information or Instructions: 

Subject Information
Last Name:* 
First Name:* 
Middle Name: 
Address:* 
Address (cont): 
City:*   
State:*  Zip Code: 
 
Date of Birth:* 
 Month Day Year

Incident/Claim Information
 
Date of Incident: 
 Month Day Year
Misc Info: 


Privacy Policy:
All information obtained from clients and on behalf of clients will remain confidential
and is only available to the client upon request. We do not sell or distribut any information
obtained from clients or on behalf of clients.