Coverage Area

 

Stumar Investigations
Surveillance Order Form

Please fill in the information requested below and we will get back to you as soon as possible.
* Denotes required field.
Deadline Date:
Claim #:
Date of Loss:
Insured:
Type of Claim:
WC Auto/BI Disability    
  Other:
Subjects Information:
Please be sure to spell correctly.

Subjects
First Name:

Last Name:
DOB: / /
Social Security#:
Address:
City: State: Zip:

Phone#:
Physical Description:      
Height: ft.   in. Weight: lbs. Hair: Facial Hair:
Sex: Male   Female Marital Status: Single     Divorced
Children:    Married, spouse's name:
Race:        
Caucasian African American Hispanic Asian Other:
Additional Info: (270 character limit)
Purpose of Surveillance: (450 character limit)
Alleged Injury:
Back Neck
Psychological, Please explain: (180 character limit)
Other, Please explain: (180 character limit)
Requestor's Information:
Adjustor/Attorney:*
Phone#:*
Company Name:
Address:*
 
City:* State:* Zip:*
Number of Days:
 
Any specific days: No Yes -
  Weekend -
  Weekday -
  Total Days: -
 
 
Name of Requestor:* 
Requestor's Email:*
Please read before you hit Submit:
If you would like a hard copy of this request, please hit print on your browser before you hit Submit.