Request Form

- Your law firm or company*
- Law firm or company address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Your name*
  
  First NameLast Name
- Your phone number
  
  Area CodePhone Number
- Your email*
  example@example.com
- Is there an additional email you would like your results sent to?
  
  YesNo
- Additional email
  Additional email where your results will be sent.
- Date of Request
  
  MonthDayYear
- Your client and/or case number*
- Date of loss*
  
  MonthDayYear
- Is this case currently in litigation?*
  
  YesNo
- What is the date this case was filed?
  
  MonthDayYear
- What is the county this case was filed in?
- Are we conducting research on a policy covering an individual (personal policy), or commercial entity?
  
  Individual (the named insured of the policy is an individual)Commercial (the named insured of the policy is a business or commercial entity)Homeowners
- Personal or Commercial?
- Please note: our hours of operation are 9am-5pm Mountain Standard Time. All processing times are subject to Pacific Liability Research's standard hours of operation.
- Information Requested*
  
  Policy Limits (includes Umbrella verificationPolicy NumberUM/UIM LimitsStandalone Umbrella LimitsHomeowner's Limits
- Personal policy type
  
  Auto PolicyUM/UIM PolicyPIP PolicyHomeowner's PolicyPersonal Umbrella
- Personal policy type
  
  Auto PolicyHomeowner's PolicyUM/UIM PolicyPersonal UmbrellaPIP Policy
- Incident type
  
  Auto/Motorcycle AccidentNeglect/AbuseWorkplace AccidentSlip & FallProduct LiabilityMedical MalpracticeBicycle AccidentAviation/Boating AccidentCatastrophic InjuryHit & RunDog BitePremises Liability
- How soon do you need your results?*
  
  4-7 business days (Standard)Next Day (12 business hours) +$100Same Day (6 business hours) +$200
- Was there a fatality involved?
  
  YesNo
- How soon do you need your results?*
  
  4-7 business days (Standard)Next Day (12 business hours) +$100Same Day (6 business hours) +$200
- Information Requested*
  
  Policy LimitsPolicy NumberWorker's Comp LimitsUM/UIM Limits
- Defendant name*
- Defendant date of birth
  
  MonthDayYear
- Defendant address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Defendant phone number
  
  Area CodePhone Number
- Defendant driver's license no.
- Vehicle year, make & model
  Defendant vehicle information.
- Vehicle VIN no.
  Defendant vehicle information.
- License plate no.
  Defendant vehicle information.
- DOT no., if applicable
  Defendant vehicle information.
- Property address of incident (if applicable)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Is defendant the property owner?*
  
  YesNoUnsure
- Is defendant also the policyholder?*
  
  YesNoUnsure
- Named insured on policy*
- Named insured date of birth
- Address of named insured
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone number of named insured
  
  Area CodePhone Number
- Insurance carrier*
- Is this insurance carrier a third party administrator?*
  
  YesNoUnsure
- Policy number
- Claim number
  If claim is not yet assigned, please enter "Unknown or N/A."
- Adjuster name
- Adjuster phone number
  
  Area CodePhone Number
- Supporting documents
  
  Please upload any supporting documents (ie., policy report, insurance letter, etc.)
  Cancelof
- Additional notes (if applicable)
  Please upload any additional notes or information related to this case which may be beneficial in conducting this investigation.
- Invoice Number
- Case Title
- Processing Time*
- Type of Insurance Discovery
- Type of Case
- Information Requested
- By entering my mobile number, I agree to receive case and account status updates from Pacific Liability Research. Message frequency varies per case investigation. Message & data rates may apply. Reply STOP to unsubscribe or HELP for help.
- Signature*
  
  by signing your name above, you agree to the terms & conditions that can be found on our website.
- I understand & accept the following terms:*
  
  all invoices are due upon receiptall deposits are non-refundableresults are not sent until invoice is paidno refunds are given for duplicate cases submitted by me or my company/firmwe reserve the right to run payment for unpaid invoices 30+ days overdue with saved payment information on file (not managed by us)
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