Assignment Request Form

*A valid email address is required to create a case. The case will not be submitted until you click the link in the confirmation email that is sent upon completion of this form.
Work to be Performed
Investigation Type Days Requested (Surveillance Only)
Other Services Required (AOE/COE, Surveillance, Background, Copy etc.)
Category
State
Type
CUSTOMER CONTACT
Assigned By * Required

First Name Last Name
Telephone No.
Company Name * Required
Office / Division
Fax No.
Company Address
Email Address * Required
Company City / State / Zip
Claim Number
Date(s) of Injury

(To )
Defense Attorney

First Name Last Name
Attorney Phone No.
Attorney Address
Attorney Email Address
Attorney City / State / Zip
EMPLOYER
Employer / Insured Name
Street Address
Contact Name

First Name Last Name
City / State / Zip
Telephone Number
Fax Number
CLAIMANT
Claimant / Subject

First Name Last Name
Home Phone Number
Social Security Number
Date of Birth
Driver's License
Occupation
Home Address
Home City / State / Zip
Height
Weight
Hair
Eyes
Gender
Ethnicity
Markings
Spouse
Dependants
Description of Injury
Work Restrictions
Comments regarding the Subject / Claimant
Claimant Physician / Medical Office
Physician / Medical Office Phone
Physician / Medical Office Address
Physician / Medical Office City / State / Zip
Claimant Attorney / Law Firm
Attorney / Law Firm Phone
Attorney Address
Attorney City / State / Zip
ADDITIONAL INFORMATION
Comments Regarding the Case
Attach Case Related Documents

Select File Description