Assign a Case

Online Request Form

No login required. Simply fill out each field of the form.

Client Information

Company
Requestor
Phone
Address
City
State
Zip
Email

A copy of this form will be sent to the email address entered in the Client Information "Email" field above.
Feel free to print a copy of the email for your records.

Video Format Preferred
CD VHS Tape
Date of Assignment
Dates To Be Conducted
Budget
Type Of Assignment
Surveillance Activity Check Background Smart Start
Insured
Insured Contact
Phone
Insured Address
City
State
Zip

Claim Information

Claim / File #
Type Of Claim / File
Claimant's Full Name
Address
City
State
Zip
Other Know Address
City
State
Zip
Have you ever contacted the Claimant using e-mail?
No Yes
Claimant Email
Phone
Type
Phone 2
Type
Phone 3
Type
SSN
Date of Birth
/ /
Race
Sex
M F
Height
Ft In
Weight
LBS
Hair Color
Hair Style
Other Characteristics
Employment Info / Current Work Status
Confidential Contact For Description
Phone
Known Vehicle Information
Date Of Injury
/ /
Alleged Injury
Scheduled Appointments
No Yes
When
Where
Represented By Attorney
No Yes
Who
Previous Surveillance Conducted
No Yes
When
Results From Previous Surveillance
Notes Regarding This Assignment

A copy of this form will be sent to the email address entered in the Company Information "email" field above. Feel free to print a copy of the email for your records.