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Client Information
Client First Name
*
*
Client Last Name
*
Client Email
*
*
*
Client Phone Number
*
Client Company Name
*
*
Address Line 2
*
Address Line 1
*
*
State
*
City
*
Zip
*
Case Details
Claim/Client Reference Number
*
*
Have you previously requested an investigation on this claim
Have you previously requested an investigation on this claim
No
Have you previously requested an investigation on this claim
Yes
Claim Type
*
Select
Workers Compensation
General Liability
Auto Liability
Property
Ancillary
Aviation Liability
Auto Theft
Cargo Liability
Cargo Theft
Commercial Umbrella Policy
Cyber
Directors & Officers
Disability
District Residency
Excess & Surplus
FECA
FELA
FMLA
Home Warranty
Inland Marine
Life and Health
Long Haul Liability
Managed Care
Management Liability
Maritime
Mortgage
Occupational Accident
Other
Professional Liability
Specialty Insurance
Stop Loss
Surety
Title
Travel Insurance
Is Subject Represented
Is Subject Represented
No
Is Subject Represented
Yes
CP Created from CP
*
Carrier and Operator Unit Companies
Carrier Company
*
Operating Unit Company
*
Defense/Client Attorney
Attorney Type
Select
Client Attorney
Plaintiff Attorney
Defense Attorney
*
Phone
*
Email
*
*
Street 1
*
ZIP/Postal Code
*
*
City
*
State/Province
*
Services
Rush
Client Due Date
*
Surveillance
Unmanned Surveillance
Number of Days
*
*
*
Value must be Numeric.
Activity Check
Alive & Well Check
Court Appearance
Database Research
AOE/COE
Recorded Statement
Scene Investigation
Subrogation Investigation
Fraud Assessment (SIU)
Social Media Investigation
Business Due Diligence
Subpoena Service
Asset Check
Locate Investigation
Service of Process
Work Check
Record Retrieval
Geo-Fence
Vehicle Locator
Medical Canvass
Hospital Canvass
Pharmacy Canvass
Clinic Canvass
Primary Physician Canvass
Physical Therapy Canvass
Chiropractic Canvass
Other Canvass
*
SCORE Basic
SCORE Advanced
SCORE Platinum
Background Investigation
Background Basic
Background Comprehensive
Background Custom
*
Background Foundational
Background Business
Auto Theft
Auto Theft
No
Auto Theft
Yes
Cargo Theft
Cargo Theft
No
Cargo Theft
Yes
Other
*
Assignment Instructions
*
*
Subject Information
First Name
*
*
Middle Name
*
Last Name
*
*
Date of Birth
*
SSN
*
Driver License
*
DL State
*
Aliases (AKA)
*
Occupation
*
Date of Hire
*
Subject Address/Telephone
Street 2
*
Street 1
*
ZIP/Postal Code
*
City
*
State/Province
*
Business Phone
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Email
*
*
Home Phone
*
Subject Demographics
Gender
Select
Male
Female
Height
*
Weight
*
Hair Color
*
Ethnicity
*
Other Description
*
Loss Description
Date of Loss
*
Check If DOL Not Available
Select
N/A
CT Date of Loss
*
Injuries
*
Check If Inj. Not Available
Select
N/A
Restrictions & Limitations
*
Description Of Loss
*
Treating Physician
*
Phone Number
*
Next Medical Appt
*
Street 1
*
Dr Appointment Time
*
Street 2
*
ZIP/Postal Code
*
*
City
*
State/Province
*
Subject Vehicle
Vehicle Description
*
Vehicle License Plate Number
*
Employer/Insured
OK to Contact Employer/Insured
OK to Contact Employer/Insured
No
OK to Contact Employer/Insured
Yes
Employer/Insured
*
*
Contact Name
*
Phone Number
*
Insured Email
*
*
Street 2
*
Street 1
*
ZIP/Postal Code
*
*
City
*
State/Province
*
Special Instructions
Trial / Hearing
*
AOE / COE Decision
*
Notes
*
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