ASSIGNMENT REQUEST

Please use this form to describe your investigative request and give us your information. By doing this online, it will give us a head start understanding your needs when we speak to you.

Type of Assignment/Claim

Worker's Comp

Activities
Check

Background
Check

Locate

Liability

Surveillance

Statement(s)

Investigation

Other

Budget:

Other comments:

Client Information

Company Name:

Client Name:

Company Address:

City:

State:

Zip Code:

Phone:

Fax:

Your Email:

SIU Number:

Claim Number:

* Mailing Instructions other than Client

Company Name:

Client Name:

Company Address:

City:

State:

Zip Code:

Phone:

Subject Information

Claimant/Subject Name:

Date of Loss:

Primary Address:

Primary City:

Primary State:

Primary Zip Code:

Primary Telephone:

Secondary Telephone:

Cell Phone:

DL #:

SSN#:

DOB:

Height

Weight

Race:

Hair

Eyes

Facial

Glasses:

Photo?

Marital Status:

# of Dependents:

Work:

Work Address:

Work Status:

Time/Days:

Work Contact:

Work Phone:

Previous Surveillance?

If Previous Surveillance Yes: When?

Comments:

Injury/Loss

Date of I/L:

Nature (MVA,SLIP/FALL,ETC):

Description of I/L:

Doctor's Name:

Address:

City:

State:

Doctor's Zip:

Doctor's Phone:

Next Scheduled Appointment:

Second Doctor's Name:

Address:

City:

State:

Doctor's Zip:

Doctor's Phone:

Next Scheduled Appointment:

Additional Information

Additional Information
(please include any additional information you believe is relevant to this case)

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