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Assignment Request Form

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Home Coverage Services Who We Are Contact Us Request Information
Assignment Request Form            * required fields
 
Type of assignment (check all that apply)*
Claim Investigation Surveillance Activity Check
Disability Interview Database Research Record Check
Neighborhood Canvas Background Check Recorded Statement
Criminal History Other:  
 
Type of Claim
Workers' Comp Auto Disability  
Liability Subrugation    
 
Budget / Due Date *
# of Surveillance Days:
 or Budget Maximum $:
 
Secure Documents (check all that apply)
Criminal Civil Other Police Report
Claim #:
Additional Claim #:
 
Assigner's Contact Information
* Last Name: * First Name:
* Company:
* Address:
Address (cont.):
* City: * State:
* Zip Code:  
* Phone Number: Fax number:
Alt Phone Number: * E-mail Address:
 
 
Preferred Method of Contact E-mail Telephone  
 
Insured / Additional Information
Insured:
Has file been previously investigated:
Is the report available:
Contact:
Additional Contact:
Phone:
ISCS to contact Insured:
Previous ISCS File #:
Additional Information or Instructions:
 
Subject Information (Fill out as much as possible)
Last Name: First Name:
Middle Name:
Alias:
Address:
Address(cont.):
City: State:
Zip Code:
Phone Number: Date of Loss:
Social Security Number: Type of Injury:
Occupation: Restrictions:
DOB:
 
Attorney
*  Is Claimant Represented:
Attorney's Name:
Address:
Address (cont.):
Phone:
 
Physical Description
Sex: Hair:
Height: Weight:
Eyes: Glasses:
Race: Marital Status:
Other Identifying Information:
 
Vehicle Information:
Vehicle Tag #: Color:
State: Doors:
Make: Model:
Vehicle 2 Information:
Vehicle Tag #: Color:
State: Doors:
Make: Model:
 
Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility:
Address:
Address (cont):
City: State:
Zip Code:  
Phone Number:
Known Appointments:
Misc. Info:
Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility:
Address:
Address (cont):
City: State:
Zip Code:  
Phone Number:
Known Appointments:
Misc. Info:
 
Other File Information:
 
Packaging: (choose all that apply)
Reports / Documents: Email HardCopy
Invoices: Email HardCopy
Video Documentation VHS CD-ROM
Preferred Documentation Shipping Method: Standard USPS Overnight
Additional Report Copies to: