To refer a case for investigation:

Contact our office at telephone number 800-531-9997 and speak with one of our account representatives to discuss solutions to your claim.

Alternatively you could use the following form.

Request Services - Online Form

Please complete and submit the information below to request services or additional information

*The more information you are able to provide, the better we will be able serve you and maximize results. However, we understand that not every cell will apply to your file and you can feel free to leave any blank that are not applicable.

INSTRUCTIONS: To navigate from one blank to the next, please press the "Tab" button on your keyboard or use your mouse to click the appropriate box. When finished completing the form, check the box at the bottom of the page and click the "Submit" button to submit your request. Thank you!

CUSTOMER INFORMATION
ALL CUSTOMERS
YOUR COMPANY:
FIRST NAME: (REQUIRED) *
LAST NAME: (REQUIRED) *
EMAIL: (REQUIRED) *
NEW CUSTOMERS
PHONE:
CELL:
ADDRESS:
CITY:
STATE:   ZIP:


CASE DETAILS
DATE OF LOSS / INJURY / DISABILITY: (MM/DD/YYYY)
BUDGET HOURS:
INSURED BUSINESS:
INSURED CONTACT FIRST NAME:
INSURED CONTACT LAST NAME:
INSURED CONTACT NUMBER:
INSURED CONTACT EMAIL:
INSURED ADDRESS:
INSURED CITY:
INSURED STATE:   ZIP:
CLAIM NO.
INSTRUCTIONS: (reasons for investigation and instructions)
SPECIAL REQUESTS: (dates for surveillance, medicals etc.)


SUBJECT DETAILS:
 
FIRST NAME:
LAST NAME:
ALIAS NICKNAME:
PHONE:
CELL:
ADDRESS:
CITY:
STATE:   ZIP:
DOB: (MM/DD/YYYY)
SSN:
GENDER:
RACE:
HEIGHT:
WEIGHT:
BUILD:
HAIR:
MARITAL STATUS:
SPOUSE NAME:

CHILDREN NAMES & AGES:
ADDITIONAL DESCRIPTION:
RESTRICTIONS/LIMITATIONS:
INJURY:
DESCRIPTION OF LOSS / ACCIDENT:
OCCUPATION:
REPRESENTED:          
DEFENSE ATTORNEY DETAILS:
CLAIMS HISTORY
RECEIVING BENEFITS
KNOWN VEHICLES:
(List Make, Model, Year)		 VEHICLE 1

VEHICLE 2

VEHICLE 3
DOCTOR 1
DOCTOR 2
DOCTOR 3
PREVIOUS SURVEILLANCE
UPLOAD DOCUMENTS (up to 3 at least)




Yes, I have reviewed the information I am submitting and it is accurate to the best of my knowledge


Thank you for taking the time to complete this form.Please click the "Submit" button if you are finished.

Please only press the SUBMIT button once and wait for the submission to process and you will receive a confirmation.
It may take up to 2 minutes for the case to be created and for us to display your case number and confirmation