Investigation Request

Client	Address
City	State
Zip	Contact
Telephone	Email
Date	Client File #
Client Requirments
How did you hear of us?	Video Format CD VHS
Type of Investigation Activities Check Background Disgruntled Employee FMLA Locate Surveillance	Length of Investigation
Specific Instructions
Trial or Hearing Date	Previous Surveillance? No Yes
Previous Report? No Yes	Previous Video? No Yes
Insured	May We Contact the Insured No Yes
Address	City
State	Zip
Contact	Telephone
Employment Application Available No Yes
Claimant's Emergency Contact	Claimant's Emergency Contact Phone
Claimant's Emergency Contact Address
Misc Info
Claimant	Address
City	State
Zip	Telephone
Other Numbers	D/O/B
SS #
Physical Description
Weight	Height
Hair	Style
Distinguishing Characteristics	Race
Photograph Available? No Yes	Marital Status Single Married Divorced Seperated Widow
Spouse's Name	Dependents
Ages	Vehicles
Date of Occurrence	Alleged Injury
Restrictions	In what capacity was the claimant employed?
Is the claimant working or off work? Working Off Work
What shift was the claimant working?	Is the claimant currently working light duty? No Yes
If yes, what is the claimant's schedule?	Believed to be working somewhere else? No Yes
Does the claimant have an attorney? No Yes	If so, has there been a deposition? No Yes
Therapy Location	Date of Next IME or Doctor's Appointment
Dr. Name	Time of Appointment
Address	City
State	Zip
Miscellaneous Information and/or Specific Instructions
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