Type of Investigation Requested

Surveillance Criminal Records Accident Scene Documentation
Recorded Statement Civil Records Background Check
Treatment Search Skip Trace Other (Please explain below)



Claimant Information
Last Name First Name
Middle Name
Social Security Number Date of Birth(mm,dd,yy)
Phone Number
Address City State Zip
Occupation Date of Loss(mm,dd,yy) Marital Status
Spouse's Name Dependants Name and Ages
Gender Race Height Weight
Prominent features:



Has claimant exhibited violent behavior? Is he/she working?
Description of injury/loss
Known physical restrictions
Description of claimant vehicles
Purpose of the investigation
Have previous investigations been conducted? If Yes, please explain
Number of surveillance days requested Specific days requested?
If needed, may we use two surveillance investigators?
Referral Date
 Estimated Start Date
 Quoted Completion Date
 Client needs report in hand by

Special instructions and/or comments







Requester Information
Last Name First Name Phone Number
Company Name Fax Number
Address (No PO Boxes) Suite/Floor #
City State Zip Email
Claim Number Claim Type Insured
How would you like to receive the report?