Claim Assignments - Accept Claims Online
Surveillance
Please provide as much information about the claim as possible
Required fields are marked by the
*
symbol and a yellow background.
If you do not have the information for a required field, please enter "unknown"
File Details and Assignment Instructions
*
Claim/File #
*
Loss Date
*
Insured/Employer
*
Type of Assignment
Video Surveillance
Activities Check
Other
*
General Assignment Instructions
Specify days for conducting surveillances
Any Day
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
No. of days authorized:
Date range:
Authorized budget for assignment:
*
Preliminary Investigation - please check all needed
Location Investigation
Activities Check
Previous Comp Claims
Civil History
Criminal History
Business Information
Driving Records
Asset Searches
Notes/Other
Client Information/Reporting Address
*
Client Company Name
*
First Name
*
Last Name
Mailing Address
Building/Suite
City
State
Zip
*
Phone #
Fax #
*
E-Mail
*
Would you like to add a 2nd contact,
such as an attorney (for reporting purposes)?
Yes
No
