AIC Web Case Referral Form

Submit A Case
Customer Information
Company Name*
Customer Name*

First NameLast Name
Email*
example@example.com
Client Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
New Assignment Information
Claim Type (if applicable)
Claim # (if applicable)
Date of Loss

MonthDayYear
Date
Loss Description

0/1000
Loss Location Address

Street Address

Street Address Line 2

CityState

Zip Code
Type of Investigation*

SurveillanceRemote SurveillanceIntelligence (Background Checks, Social Media, Etc.)Field Investigations (AOE/COE, Recorded Statements, Scene Investigations)SIU
Surveillance
Remote Surveillance
Surveillance - Number of Hours
Remote Surveillance - Number of Hours
Field Investigation
SIU
Intelligence Services
Medical Canvass Facility Types (list)

HospitalPharmacyWalk-in / Urgent CarePrimary / PCPImaging / MRIChiropracticOrthopedicPhysical TherapyPain ManagementNeurosurgery / NeurologyCardiologyPodiatryOptometry/OpthalmologyDentalGymOther (Describe Below)
If "Other" enter type of Facility:
Medical Canvass Facility Types
Facility Count
Budget (if applicable)
Enter a dollar amount or number of hours
Due Date

MonthDayYear
Date
Assignment Instructions

0/1500
Surveillance Requested Date #1

MonthDayYear
Date
Surveillance Requested Date #2

MonthDayYear
Date
Surveillance Requested Date #3

MonthDayYear
Date
Surveillance Requested Date #4

MonthDayYear
Date
Surveillance Requested Date #5

MonthDayYear
Date
Surveillance Requested Date #6

MonthDayYear
Date
Surveillance Requested Date #7

MonthDayYear
Date
Claimant/Subject Information
Name*

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Do you have prior address(es) to provide?

YesNo
Prior Address(es)

0/500
Driver's License #
SSN
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Claimant/Subject Description
Gender

FemaleMale
Race

WhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsianHispanicNative Hawaiian or Pacific IslanderOther
Height
Weight (lbs)
Hair color

BlackBlondeBrownGreyRedWhiteMulti-ColorOther
Eye Color

BlackBlueBrownGreenHazelOther
Additional Description Details

0/1000
Married

YesNoUknownN/A
Spouse or Partner Name (if known)
Children

List the number of kids and their ages0/500
Previous Surveillance

YesNoUknownN/A
Upcoming Appointments

YesNoUknownN/A
Appointment Date 1

MonthDayYear
Date
Appointment Date 2

MonthDayYear
Date
Appointment Details

0/500
Vehicle Description

0/500
Are there injuries or restrictions to report?

YesNo
Injury

List all injuries with claim0/1000
Restrictions

0/1000
Currently Employed?

N/AYesNo
Current Employer Information
Current Employer Contact Information
Additional Claimants?

YesNo
Additional Claimant(s)*
Witnesses?

YesNo
Witness(es)*
Do you have Insured information to provide?

YesNo
Insured Information
Check if Insured Information is the same as Claimant:

Yes
Name

First NameMiddle Name/InitialLast Name
Company Name
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
DOB

MonthDayYear
Date
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Information
Company Name
Contact Person Name

First NameMiddle Name/InitialLast Name
Work Phone
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Email
example@example.com
Attorney Information
Attorney involved?

Yes
Name

First NameMiddle NameLast Name
Firm Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you have additional information to provide?

YesNo
Additional Information
Third-Party Name
Third-Party Contact
C.C. Party Information

0/1000
Special Instructions

0/500
Do you have Billing information to provide?

YesNo
Reporting / Billing Instructions

For New Clients
Report sent to Name and Email (if different from above)
CC Report sent to Name and Email (if applicable)
Billing Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill sent to Name and Email (if different from above)
Other Comments and Instructions

0/500
File Upload
File Upload

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Submit A Case

Customer Information

New Assignment Information

Claimant/Subject Information

Claimant/Subject Description

Insured Information

Employer Information

Attorney Information

Additional Information

Reporting / Billing Instructions

File Upload