877.990.2111

Licensed In: FL, AL, GA, SC, NC, VA, TN, WV, PA, OH, NJ MD, DE, DC

Assign a New Case

Client Info:
  1. Company
  2. (required)
  3. Adjuster Name
  4. (required)
  5. Email Confimation
  6. (valid email required)
  7. make sure email is correct...
  8. Investigative Service
  9. (required)
  10. Days of Surveillance
  11. Mailing Address
  12. (required)
  13. Phone
  14. (required)
Subject/Claimant Info:
  1. Claim #
  2. (required)
  3. Claimant Name
  4. (required)
  5. Claimant Address
  6. (required)
  7. Claimant Phone #
  8. (required)
  9. SS# (Secure)
  10. (required)
  11. Date of Birth
  12. (required)
  13. Date of Loss
  14. (required)
  15. Case Due Date
  16. Claimant Working? (Yes/No)
  17. Working Hours & Location
  18. (required)
  19. Type of Injury
  20. (required)
  21. First Report of Injury
  22. Photo ID
  23. Misc. Document 1
  24. Misc. Document 2
  25. Misc. Document 3
  26. Race
  27. Gender
  28. Height
  29. Weight
  30. Hair Color
  31. Eye Color
  32. Other Phyiscal Characteristics
  33. Visible Handicaps
  34. Scheduled Appointments
  35. Facility & Address
  36. Vehicle Information
  37. Previous Surveillance
  38. Represented by Attorney
Special Instructions:
Notes: