Assignment Request Form

Type of assignment (check all that apply)*

Claim Investigation
Database Research
Recorded Statement
Activity Check
Record Check
Criminal History
Neighborhood Canvas
Disability Interview
Background Check

Type of Claim

Workers' Comp Auto Disability Liability Subrogation

Budget/Due Date*

Secure Documents (check all that apply)

Criminal Other Police Report

Assigner's Contact Information

Prefered Method of Contact

Email Telephone

Insured/Additional Information

Subject Information (Fill out as much as possible)


Physical Description

Vehicle Information

Vehicle 2 Information

Treating Doctor/Rehab Facility Information

Treating Doctor/Rehab Facility Information

Other File Information

Packaging (choose all that apply)

Email Hard Copy

Email Hard Copy

Hyperlink CD-ROM

Standard USPS Overnight

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