INVESTIGATION REQUEST FORM
Date Assigned:
Verbal Report Due:
Written Report Due:
Research Type:

TYPE OF INVESTIGATION
Background
Locate
Activity/LEC
Asset
Surveillance
Personal Contact/Other
Social Networking
AOE/COE
Liability
Subrogation

SUBJECT INFORMATION      
First Name / Middle / Last Name

DOB

SS#
Race
Current Address

Sex
M
F
Height
Weight
Hair
Eyes

City, State, ZIP

Marital Status

Spouse
AKAs
Telephone

R/L Handed
Right
Left
Glasses
Yes
No
Complexion
Identifying Features
Previous Address, City, State, ZIP


Current Occupation
Occupation at Time of Injury

CLAIM/INJURY DETAILS
Insured/RE
SIU No.
Claim No.
Date of Injury
Injuries
Subjective Complaints
Description of How Injury Occurred
Miscellaneous Information or Special Instructions
Physician
Date of Next Medical Exam
IME
Attorney
Deposition
Date of Hearing/Trial

BILLING/REPORTING INSTRUCTIONS (yellow fields indicate required information)
Name
Company
Address


City, State, ZIP
Email Address
Telephone
 
Copy to:
Special Notes/Instructions: