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Client Information
Client First Name
*
*
Client Last Name
*
Client Email
*
*
*
Client Phone Number
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Client Company Name
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*
Address Line 1
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*
Address Line 2
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City
*
State
*
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
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Workers Compensation
General Liability
Auto Liability
Life and Health
Disability
Mortgage
Maritime
Property
FMLA
Other
FECA
Is Subject Represented
Is Subject Represented
No
Is Subject Represented
Yes
CP Created from CP
*
Defense/Client Attorney
Attorney Type
Client Attorney
Plantiff Attorney
Defense Attorney
*
Phone
*
Email
*
*
Street 1
*
ZIP/Postal Code
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*
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
SIU Investigation
Social Media Investigation
Business Due Diligence
Subpoena Service
Asset Check
Locate Investigation
Service of Process
Work Check
SCORE
Record Retrieval
Geo-Fence
Vehicle Locator
Background Basic
Background Comprehensive
Background Custom
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Background Investigation
Hospital Canvass
Pharmacy Canvass
Clinic Canvass
Medical Canvass
Physical Therapy Canvas
Chiropractic Canvass
Other Canvass
*
Primary Physician Canvass
Other
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Assignment Instructions
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*
Subject Information
First Name
*
*
Middle Name
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Last Name
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*
Date of Birth
*
SSN
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Driver License
*
DL State
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Aliases (AKA)
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Occupation
*
Date of Hire
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Subject Address/Telephone
Street 2
*
Street 1
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ZIP/Postal Code
*
City
*
State/Province
*
Business Phone
*
Email
*
*
Home Phone
*
Subject Demographics
Gender
Male
Female
Height
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Weight
*
Hair Color
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Ethnicity
*
Other Description
*
Loss Description
Date of Loss
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Injuries
*
Restrictions & Limitations
*
Description Of Loss
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Treating Physician
*
Phone Number
*
Next Medical Appt
*
Street 1
*
Dr Appointment Time
*
Street 2
*
City
*
State/Province
*
ZIP/Postal Code
*
*
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
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AOE / COE Decision
*
Notes
*
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