(Workers' Compensation Investigation)
CLIENT = The person filling out this form.
CLIENT: (HOW SHOULD WE COMMUNICATE WITH YOU?)
Regular Text Messaging
CLIENT: Phone Number or Email Address based on your answer to the above question.
CLIENT: Full Name
CLIENT: Company Name
CLIENT: Company Address
CLIENT: What are you trying to accomplish?
(This would typically be there person that investigators need to follow and document activity)
CLAIMANT: Full Name
CLAIMANT: Home Address
CLAIMANT: Work Address, if applicable to surveillance needs.
CLAIMANT: Physical description, height, weight, race, gender, glasses, etc.
CLAIMANT: Vehicles, color, year, make model, tag number
CLAIMANT: Describe the injury and or physical limitations of the claimant and the types of movements the investigator should focus on while videotaping.
CLAIMANT: Other information the investigator may need to know.
CLIENT AGREEMENT: This is an agreement between AAA Surveillance, Inc. and CLIENT. The parties agree that AAA Surveillance, Inc. shall provide CLIENT with Private Investigative Services which may result in; typed reports, recorded statement, printed documents, photographs, videotape evidence and/or related materials. CLIENT agrees to pay AAA Surveillance, Inc. an hourly rate plus necessary and reasonable expenses. CLIENT understands that AAA Surveillance, Inc investigators must comply with Federal, State and County laws while conducting the investigation. Investigators are not allowed to trespass or make phone calls (pretexting) pretending to be someone that they are not in order to gain evidence. AAA Surveillance, Inc. has the right to refuse any request by CLIENT it deems inappropriate. AAA Surveillance, Inc. has the right to refuse any case, for any reason. Submission of this form does not signify acceptance of your case.
SURVEILLANCE PRICING: Surveillance is invoiced at $75 per hour, plus tax and $0.60 cents per mile. Invoicing begins when the investigator leaves the Millersville area (or personal residence) and continues until they return at the conclusion of surveillance. A second investigator can be added at a rate of $60 per hour, plus tax. Additional fees may include; tolls, parking, event entrance fees, bar or restaurant (as required as part of surveillance). A typed report is provided upon full payment of the invoice. No work is performed on your case without your prior authorization.
COURT TESTIMONY: Court testimony is invoiced at $500 per half a day, plus travel time and $0.65 cents per mile. Invoicing begins when the investigator leaves the Millersville area and continues until returning to the Millersville area. A retainer is required 7 days prior to the appearance date of court. No refunds in the event of rescheduling or cancellation.
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform