Investigation Request Form
Subject :
State
New Assignment
Re-Assignment   Our File #   Date
Requester Information:
Requester:
Company :
Adjuster: Company:
Telephone: Email:
Claim/File#: Pick one:   WC    Liability   Other
Insured:
Injury:
Date of Loss:
Subject Information:
Subject’s Full Name:
Address:
City: State: Zip:
Telephone:
DOB: SS#:
Occupation:
Gender: Male    Female Race:
Height: Weight: Hair Color:
Children:
Married: Yes   No
If Yes, spouse’s name:
Other Characteristics: (i.e. glasses, tattoos, scars)
Is Subject Represented? Yes   No
Name/Law Firm:
Is Subject Being Paid? Yes   No

Address where checks are sent:

Type of Investigation:
Assignment taken by:
Activity Check Surveillance Special
Budget:
Instructions/Message:
Update your SIU person? Yes    No
Name: Telephone:
Update your attorney? Yes   No
Name: Telephone:
Prior Investigations? Yes   No
Results:
Acknowledgement: Letter   Phone Call
Additional Assignment Sheets? Yes   No
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