Criminal and or Civil Background Check Order Form

Criminal and or Civil Background Check Order Form
Agency License #: A-98-00005

Form Type:

Type of Check:

Civil Background Check
Criminal Background Check
Civil and Criminal Background Check

Claim Rep:

Claim #:

Insured:

Return To (if surveillance needs to be sent to defense counsel enter attorney name here):

Subject:

Last Known Address:

City:

State:

Zip:

Date Of Birth:

S.S. Number (Must have Social Security Number to run Civil or Criminal Background Check).:

FL DL #:

(Please list all identifying information you have as due to data truncation we do not have access to complete Social Security Numbers)

Last Known Phone Number:

Date of Loss:

Any Additional Information On Subject:

Please Specify Reason for Background Check:

Client's Comments To Investigator:

Rush Assignment:

YesNo

There is an additional $75 rush charge for all assignments that must be returned within 1 week.

Your Contact Information

First Name:

Last Name:

Company Name:

Address Line1:

Address Line2:

City:

State:

Zip Code:

Country:

Preferred Phone #:

Secondary Phone #:

Email Address:

Defense Counsel and or Adjuster Contact Information