Assign a New Case

Client Info:
  1. Company
  2. (required)
  3. Adjuster Name
  4. (required)
  5. Email Confimation
  6. (valid email required)
  7. Investigative Service
  8. (required)
  11. Days of Surveillance
  13. Mailing Address
  14. (required)
  15. Phone
  16. (required)
Subject/Claimant Info:
  1. Claim #
  2. (required)
  3. Claimant Name
  4. (required)
  5. Claimant Address
  6. (required)
  7. Claimant Phone #
  8. (required)
  9. SS# (Secure)
  10. (required)
  11. Date of Birth
  12. (required)
  13. Date of Loss
  14. (required)
  15. Case Due Date
  17. Claimant Working? (Yes/No)
  19. Working Hours & Location
  21. Type of Injury
  22. (required)
  23. First Report of Injury
  25. Photo ID
  27. Misc. Document 1
  29. Misc. Document 2
  31. Misc. Document 3
  33. Race
  35. Gender
  37. Height
  39. Weight
  41. Hair Color
  43. Eye Color
  45. Other Phyiscal Characteristics
  47. Visible Handicaps
  49. Scheduled Appointments
  51. Facility & Address
  53. Vehicle Information
  55. Previous Surveillance
  57. Represented by Attorney
Special Instructions:
Notes: