Insurance Surveillance Case Request Form

To submit a case, please fill in as much information as possible and click on the "Submit" button toward the bottom of the page.  We will provide confirmation of receipt via email or phone.

Assignment

Complete Case By:

Claimant Information

Name: (first, mi, last)

Last Known Address

Apartment, Lot or Suite:

City:

State:

Zip:

Phone:

Alternate Phone:

Date of Birth:

Social Security Number:

Employer Name:
Employer Address:
Employer Phone:
Position Held:

Claimant Identifiers

Race:

Sex:
Build:
Height:
Weight:
Glasses:

Facial Hair:
Hair Length/Color:
Marital Status:
Children:
Background:
Drivers License Number:
Vehicles:

Claim Information

Claim Number:

Type of Claim:

Date of Loss:

Insured:

Alleged Injury:

Limitations:

Claimant's Doctor Information

Doctor Name:

Doctor Address:

Doctor Phone:

Scheduled Appointments:

Claimant's Attorney Information

Attorney Name:

Attorney Address:

Attorney Phone:

Scheduled Appointments:

Client Information

Requester:

Company:

Mailing Address:

Suite:

City:

State:

Zip:

Phone:

Fax:

Email:

Defense Attorney Information

Attorney:

Firm Name:

Mailing Address:

Suite:

City:

State:

Zip:

Phone:

Fax:

Email:

Send Copy of Report and Video to Attorney:

Yes  No

Comments and Special Instructions

Enter the following code to proceed:  pig101:

If an email is provided, we will send an email confirming receipt of case information. If you do not receive a confirmation email within a few hours, please resend or call.

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PIG Private Investigators