Insurance Case Assignment Form

Client Information
Company	Requestor
Address	Suite/Apt.
City	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	ZIP
Phone --	Fax --	Email Address
Assignment Type Please Choose Surveillance Background Interviews Activity Check Other (please specify)	If Other (Assignment Type)
Assignment Date Month -- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year	Assignment Duration # of Days
How would you like to receive video? Online via Secure Client Login         VHS         DVD   How would you like to receive reports? Online via Secure Client Login         Mail         Email

Employer Information
Employer	Insured Contact	May we contact? Yes    No
Address	Suite/Apt.
City	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	ZIP
Phone 1 --	Phone 2 --	Email Address

Claimant Information
Claim #	Type of Claim
Claimant's Full Name		Social Security # --
Address	Suite/Apt.
City	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	ZIP
Phone --	Mobile --	Other Phone --
Confidential Contact for description		Contact Phone --
Sex Please Choose Male Female Unknown	Race Please Choose White Black Hispanic Asian Native	Date of Birth
Height ft.    in.	Weight lbs.	Glasses Yes    No
Hair Color Please Choose Black Brown Blonde Red Brunette Salt/Pepper Gray Other	Hair Style
Other Descriptive Details (tattoos, disabilities, scars, etc.)
Marital Status Please Choose Single Married Divorced Separated Widowed Co-Habiting Unknown	Receiving Benefits? Yes    No	If yes to benefits, list where
Children Yes    No	# of Children	If yes to children, list ages
Known Vehicle Info

Injury Information
Injury Date Month -- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year	Injury Description
Scheduled Dr. Appointments? Yes    No	If yes, list dates and physicians
Represented by Attorney Yes    No	If yes, list attorney name
Previous Surveillance Conducted? Yes    No	If yes, list dates and locations
Previous Surveillance Reports
Special Instructions