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To Our Clients: Please read carefully.

We do not want important information to be left out when you send us this Investigative Request Form, so we ask that you fill in every text field before you submit it to us.

If you do not type investigative information into a line, please indicate to us that you have seen each line by typing in any keyboard character (s), such as: n/a, xx, or --- as a fill-in for the required text.

We hope this is not inconvenient. We want to give you the best possible service.

Thank you.

Client Contact Information
First Name:		Claim / Case #:
Last Name:		Date of Loss:
Company:		Insured:
Address
City:		Type of search or investigation needed
State:		Services:
Zip:
Phone:
Email:		How did you hear about us?
Fax:

Subject Information		Subject Description
First Name:		Race
Middle Name		Hair Color:
Last Name:		Approx. Height:	Feet Inches:
Address:		Approx. Weight:
City:		Sex:
State:		Marital Status:
Zip:		Spouse's Name:
Phone:		Comments:
DOB:
SSN:
Driver's Lic. #
Vehicle Information:

Employer Information
Company:		Contact Name
Address:		Phone:
City, State, Zip:		Email:

Physician Information
Name:		Phone:
Address:		Comments:
City, State, Zip:

Plaintiff Attorney Information
Name:		Phone:
Address:		Comments:
City, State, Zip:

Defendant's Attorney Information
Name:		Phone:
Address:		Comments:
City, State, Zip:

Case Specifics
Please conduct surveillance on:
Please update me by:
Please be aware of these restrictions:
Send my report via:
Video Format:
Specific Instructions / Objectives:

Due Date:

DO NOT EXCEED	WITHOUT FURTHER AUTHORIZATION
Please enter the code as it is shown below (this field helps prevent automated access):
(Be sure that each line contains fill-in text.) * Confirmation will be sent via email within 24 hrs.

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