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Customer Information
Company Name
*
Customer Name
*
First Name
Last Name
Email
*
example@example.com
Client Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
New Assignment Information
Claim Type (if applicable)
Please Select
Casualty
Workers' Compensation
Liability
Auto
FMLA
Property
Medical Malpractice
Other
Claim # (if applicable)
Date of Loss
-
Month
-
Day
Year
Date
Loss Description
0/1000
Loss Location Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Type of Investigation
*
Surveillance
Remote Surveillance
Intelligence (Background Checks, Social Media, Etc.)
Field Investigations (AOE/COE, Recorded Statements, Scene Investigations)
SIU
Surveillance
Please Select
24 Hour Video Surveillance
Activity Check
Activity Check/Neighborhood Canvass (Allied)
Alive & Well/Life Style Check (Allied)
Command Functions
Court Appearance
Covert Activity Check
Orientation
Overt Activity Check
SI-Activity Check (2 Hours)
SI-Activity Check (Half Day RUSH)
SI-Activity Check (Half Day)
SI-Activity Check (RUSH)
Surveillance AL
Surveillance AR
Surveillance AZ
Surveillance CA
Surveillance CO
Surveillance CT
Surveillance DE
Surveillance FL
Surveillance GA
Surveillance IA
Surveillance ID
Surveillance IL
Surveillance IN
Surveillance KS
Surveillance KY
Surveillance LA
Surveillance MD
Surveillance MI
Surveillance MO
Surveillance MS
Surveillance NC
Surveillance NJ
Surveillance NM
Surveillance NV
Surveillance NY
Surveillance OH
Surveillance OK
Surveillance OR
Surveillance PA
Surveillance PA
Surveillance SC
Surveillance TN
Surveillance TX
Surveillance UT
Surveillance VA
Surveillance WA
Surveillance WV
Vehicle Sighting Report
Remote Surveillance
Please Select
Remote Surveillance
Remote Surveillance AL
Remote Surveillance AZ
Remote Surveillance AZ
Remote Surveillance CA
Remote Surveillance CO
Remote Surveillance CT
Remote Surveillance GA
Remote Surveillance IL
Remote Surveillance IN
Remote Surveillance LA
Remote Surveillance MD
Remote Surveillance MI
Remote Surveillance MO
Remote Surveillance NC
Remote Surveillance NJ
Remote Surveillance NM
Remote Surveillance NY
Remote Surveillance OH
Remote Surveillance OK
Remote Surveillance OR
Remote Surveillance PA
Remote Surveillance PA
Remote Surveillance RI
Remote Surveillance SC
Remote Surveillance TN
Remote Surveillance TX
Remote Surveillance VA
Remote Surveillance WV
VMP Remote Surveillance
Surveillance - Number of Hours
Please Select
56 (7 days)
48 (6 days)
40 (5 days)
32 (4 days)
24 (3 days)
16 (2 days)
8 (1 day)
Remote Surveillance - Number of Hours
Please Select
56 (7 days)
48 (6 days)
40 (5 days)
32 (4 days)
24 (3 days)
16 (2 days)
8 (1 day)
Field Investigation
Please Select
Alive and Well Check
AOE/COE
AOE/COE CA
Asbestos
Claims
Claims Investigation
Dependency Check
Field Investigation
Locate
Locate (Skip Trace)
Loss Prevention Interview
Process Serve
Record Retrieval
Recorded Statement
Rent Board
Scene Investigation
SIU Investigation
Transcription
SIU
Please Select
Insurance/SIU
Record Retrieval
SIU Claim Investigation
SIU Compliance
SIU Court Tracking
SIU Doctor Review
SIU Evidence Presentation
SIU File Retrieval
SIU Fraud Analysis & Assessment (A&A)
SIU Fraud Analysis & Referral Combo (Davies)
SIU Interview
SIU State Fraud Referral
SIU State Fraud Submission
SIU Video Inspection
Work Place
Intelligence Services
Please Select
Asset Check
Asset Investigation (Advanced)
Asset Investigation (Intermediate)
Asset Investigation (Standard)
Background Comprehensive
Background Investigation (Advanced)
Background Investigation (Intermediate)
Background Investigation (Standard)
Background Limited
Basic Social Media
Board Member Check
Business Search
Civil and Criminal Check
Civil Only Check
Commercial Auto Liability Investigation
Comprehensive Background
Comprehensive Background Check
Comprehensive Civil Only Check
Criminal Conviction Check
Death Record Check
Desktop (Pre-Surveillance) Activity Check
Desktop Activity Check
Discovery Package
Divorce Record Check
DMV Check
Executive Background
Executive Background Plus
Fishing License Check
Hunting License Check
JC Background
JC Death/Marital Status Check
JC Property Records Search
Legal (Trial Preparation)
Limited Background
Litigation Search
Locate (Skip Trace)
Marriage Record Check
Medical Canvass
Medical Canvass 8
Medical Canvass 10
Medical Canvass 12
Medical Canvass 15
Medical Canvass 18
Medical Canvass 24
Medical Canvass 30
Medical Canvass 32
Medical Canvass 36
Motor Vehicle Registration Search
National Profile Report
Police Report
Pre Investigation
Prelim
PreScreen-Gratis Service
Process Serve
Process Serve (Rush Rate)
Process Serve/Document Retrieval
Professional License Check
Real Property/Asset Check
Record Retrieval
Reports - Obtaining Police, Fire, Coroner Reports
SIU Initial Background (Auto Theft)
SIU Initial Background (Bodily Injury Auto Accident)
SIU Initial Background (Insured Business)
SIU Initial Background w/Basic social media (Homeowners)
SIU Initial Background w/Basic social media (Insured Individual - Commercial)
SIU Initial Discovery Package (Bodily Injury – Non-Auto)
Skip Tracing/Individual Locate
Social Media & Background Investigation
Social Media (Advanced)
Social Media (Standard)
Social Media Analysis
Social Media Data Details
Social Media Investigation
Social Media Monitoring
Social Media Monitoring-Limited
Social Media Preservation
Social Media Profile
Social Media Profile - Limited
Social Media with Background
Social Security Number Search
SSN Verification
Standard Background
State Driver's History Record
Statewide Criminal Check
Subrogation Investigations
Theft Investigation
Vehicle Sighting Report
WebTAP
Work Comp State Record Search
Medical Canvass Facility Types (list)
Hospital
Pharmacy
Walk-in / Urgent Care
Primary / PCP
Imaging / MRI
Chiropractic
Orthopedic
Physical Therapy
Pain Management
Neurosurgery / Neurology
Cardiology
Podiatry
Optometry/Opthalmology
Dental
Gym
Other (Describe Below)
If "Other" enter type of Facility:
Medical Canvass Facility Types
Facility Count
Please Select
24
18
12
Budget (if applicable)
Enter a dollar amount or number of hours
Due Date
-
Month
-
Day
Year
Date
Assignment Instructions
0/1500
Surveillance Requested Date #1
-
Month
-
Day
Year
Date
Surveillance Requested Date #2
-
Month
-
Day
Year
Date
Surveillance Requested Date #3
-
Month
-
Day
Year
Date
Surveillance Requested Date #4
-
Month
-
Day
Year
Date
Surveillance Requested Date #5
-
Month
-
Day
Year
Date
Surveillance Requested Date #6
-
Month
-
Day
Year
Date
Surveillance Requested Date #7
-
Month
-
Day
Year
Date
Claimant/Subject Information
Name
*
First Name
Middle Name
Last Name
Current Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have prior address(es) to provide?
Yes
No
Prior Address(es)
0/500
Driver's License #
SSN
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Claimant/Subject Description
Gender
Female
Male
Race
White
Black or African American
American Indian or Alaskan Native
Asian
Hispanic
Native Hawaiian or Pacific Islander
Other
Height
Weight (lbs)
Hair color
Black
Blonde
Brown
Grey
Red
White
Multi-Color
Other
Eye Color
Black
Blue
Brown
Green
Hazel
Other
Additional Description Details
0/1000
Married
Yes
No
Uknown
N/A
Spouse or Partner Name (if known)
Children
List the number of kids and their ages
0/500
Previous Surveillance
Yes
No
Uknown
N/A
Upcoming Appointments
Yes
No
Uknown
N/A
Appointment Date 1
-
Month
-
Day
Year
Date
Appointment Date 2
-
Month
-
Day
Year
Date
Appointment Details
0/500
Vehicle Description
0/500
Are there injuries or restrictions to report?
Yes
No
Injury
List all injuries with claim
0/1000
Restrictions
0/1000
Currently Employed?
N/A
Yes
No
Current Employer Information
Current Employer Contact Information
Additional Claimants?
Yes
No
Additional Claimant(s)
*
Witnesses?
Yes
No
Witness(es)
*
Do you have Insured information to provide?
Yes
No
Insured Information
Check if Insured Information is the same as Claimant:
Yes
Name
First Name
Middle Name/Initial
Last Name
Company Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
DOB
-
Month
-
Day
Year
Date
SSN
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Information
Company Name
Contact Person Name
First Name
Middle Name/Initial
Last Name
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Attorney Information
Attorney involved?
Yes
Name
First Name
Middle Name
Last Name
Firm Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have additional information to provide?
Yes
No
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?
Yes
No
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
City
State / Province
Postal / Zip Code
Bill sent to Name and Email (if different from above)
Other Comments and Instructions
0/500
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