New Assignment
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CLAIMANT (SUBJECT) INFORMATION
SUBJECT(S) DETAILS:
Name, Address, Phone, DOB, SSN, Vehicle/Owner/Ins Carrier, DL#
SUBJECT EMPLOYER DETAILS:
Company Name, Address, Occupation, Lost Time, Return to Work, Restrictions
CLAIM NUMBER:
DATE OF LOSS:
ASSURED:
Insured
CLAIMANT ATTORNEY:
Name, Address, Phone
INJURY DETAILS:
Injury, Hospitals, Doctor, PT, DC
CASE TYPE:
Liability
Work Comp
Subrogation
UM Claim
Other
REQUESTED WORK
Requested Work:
Activities Check
Bodily Injury
Claims Background
Complete Story
Contestable Death
Decedent check
Disability Claim
Employment
Injury History
Intelligence Report
Internet Monitoring
Locate
Online Investigations
Pre-Employment
Records Check
Remote Surveillance
Skip Tracing
Statements
Subrogation
Surveillance
Wrongful Death
UPLOAD CASE FILES:
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SPECIAL INSTRUCTIONS:
CLIENT INFORMATION
Client Name:
*
First Name
Last Name
Client Email:
*
example@example.com
Client Phone Number:
*
-
Area Code
Phone Number
Client Company:
Client Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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