Investigation Request Form

Date of Assignment:(mm/dd/yyyy)
Type of Assignment:	Surveillance Background Other
Specific Dates to be Conducted:
Client Company Name:
Requester:
Mailing Address:(city, state, zip)
Phone #:
Insured:
Insured Contact:
Phone #:
Insured Address:
Claim Information
Claim #/File#:
Type of Claim/File:
Claimant's Full Name:
Phone #:
Address:
Other Known Address:(city, state, zipcode)
Other known phone#:
Brief Description:
Social Security #:
Date of Birth:(mm/dd/yyyy)
Race:	White Hispanic Black Asian Other
Gender:	Male Female
Height:
Weight:
Hair Color:
Hair Style:
Facial Hair:
Other Characteristics:
Confidential Contact for Description:
Phone #:
Known Vehicle Informaion From Client:
Date of Injury:
Alleged Injury:
Any Scheduled Appointments:	Yes
If yes, when?
Where:
Is Claimant Represented by an Attorney?	Yes
If yes, who?
Has previous surveillance been conducted?	Yes
If yes, when?
Results of previous surveillance?
Any cautions regarding this assignment?
Additional information: