Insurance Case Assignment Form

Client Information
Are you a first time client? Yes No
Company:
Requestor	Phone
Address	Suite/Apt.
City	State	ZIP:
Assignment Date	# of Days
Video Format	VHS DVD
Reports	Mail E-mail
Assignment Category	Surveillance Background Interviews Activity Check AOE/COE
	Other:
Employer Information
Employer	Insured Contact:	May we contact? Yes No
Address	Suite.
City	State	ZIP:
Phone 1	Phone 2	Email Address
Claimant Information
Claim #	Claim Type
Claim #		SS#
Address	Suite/Apt.
City	State	ZIP:
Confidential Contact for description		Contact #
Sex M F	DOB	Race
Height	Weight	Hair Color
Glasses Yes No	Other Characteristics (facial hair, markings, etc...)
Marital Status	Children Yes No	# of Children
Known Vehicle Info		Receiving Benefits Yes No
Injury Information
Injury Date	Injury Description
Scheduled Appointments Yes No	Injury Date	Physician
Represented by Attorney Yes No	Attorney Name	Dates/Location
Previous Surveillance Conducted Yes No	Previous Surveillance Reports
Special Instructions