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Type of Investigation

Budget: Amount of money, Number of days, or Specific day:

Deadline:

Completion Date:

Previous Investigations: (If yes, please forward prior reports)

Special Instructions:

Client Information

Client/Requestor Name:

Company Name:

Address:

City:

State:

Zip:

Phone Number:

Client/Requestor Email Address:

Are you requesting this for someone else?

For whom?

CC Report?

To whom?

Attorney?

Name, Firm, Phone and Email:

Please contact me to discuss further.

Return confirmation email requested.

Claim Information

Other:

Claim/File Number or N/A:

Date of Loss:

Job Description/Title:

How did accident happen?

Location of accident?

Is subject still working?

Insured's Company Name:

Insured's Contact and Phone Number:

Insured's Address:

City:

State:

Zip:

Claimant Information

First Name:

Middle Name/Initial:

Last Name:

Address:

City:

State:

Zip:

Is subject receiving benefits at this address?

Alternate Address:

Address:

City:

State:

Zip:

Phone Number:

Cell Number:

Social Security Number:

Date of Birth:

Race:

Sex:

Male
Female
Unknown

Type of Injury:

Height:

Weight:

Hair:

Eyes:

Physical Characteristics:

Type of clothing normally worn:

Does Claimant have a criminal or violent history?

If yes, please explain:

Children: List ages/gender:

Vehicles: List all make/model/color/tags, if known:

Treatment Information

Is subject actively treating? If yes, provide details below.

Name:

Address:

Phone Number:

Dates/Times:

Next Treatment Date:

Are we to cover this date?

Subject Attorney

Is Subject represented? If yes, provide details below.

Law Firm Name:

Attorney Name:

Additional Case Notes

Miscellaneous Information:

Add Attachments:

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