Assignment Request Form

Type of assignment (check all that apply)*

Claim Investigation
Database Research
Recorded Statement
Activity Check
Record Check
Criminal History
Surveillance
Neighborhood Canvas
Other
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)
















Attorney





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

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