Assign a new case

Customers can use this form to open a new case or submit additional documentation for active cases.

Client Information:

Company:(Required)

Adjuster Name:(Required)

Email:(Required)

Enter Email Confirm Email

Valid Email Required

Investigative Service:(Required)

Investigative Service:

Days of Surveillance:

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone:(Required)

Subject/Claimant Information:

Claim Number:(Required)

Claimant Name:(Required)

Claimant Address:(Required)

Street Address Address Line 2 City State ZIP Code

Claimant Phone:(Required)

SS# (Secure):(Required)

Date of Birth:(Required)

Date of Loss:(Required)

Case Due Date:

Claimant Working?

Yes

Working Hours & Location:

Type of Injury:(Required)

First Report of Injury:

Max. file size: 512 MB.

Photo: ID:

Max. file size: 512 MB.

Misc. Document 1:

Max. file size: 512 MB.

Misc. Document 2:

Max. file size: 512 MB.

Misc. Document 3:

Max. file size: 512 MB.

Gender:

Race:

Height:

Weight:

Hair Color:

Eye Color:

Other Phyiscal Characteristics:

Visible Handicaps:

Scheduled Appointments:

Facility & Address:

Vehicle Information:

Previous Surveillance:

Yes

Represented by Attorney:

Yes

Special Instructions:

Notes:

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Assign a new case

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Client Information:

Subject/Claimant Information:

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