Surveillance Order Form

Surveillance Order Form
Agency License #: A-98-00005
Form Type:
Claim Rep:
Claim #:
Insured:
Return To (if surveillance needs to be sent to defense counsel enter attorney name here):
Claimant Name:
Address:
City:
State:
Zip:
Phone:
Race:
Sex:
Height:
Weight:
Check all that apply: BeardMustacheGlasses
Hair Length and Color:
Further Descriptive Details:
Date of birth:
Social Security Number:
(Please list all Identifying information: DOB/SSN/DL #, as this information may become vital if the surveillance assignment turns into a locate investigation)
Spouses Name:
Spouses Date of birth:
Children:
Alleged Injury:
Physical Restrictions:
Date of Loss:
Type of Claim:
Claimants Vehicles:
Claimants Occupation:
FormerPresentUnknown

Claimants Employer Name:
Claimants Doctor (Name & Address):
Next Scheduled Appointment:
Claimants Attorney (Name & Address):
Client's Comments To Investigator:
Number of Days:
(Note: If requesting weekend days we recommend that you already have specific knowledge that your claimant/subject is active or involved in specific activities on the weekend (because weekend activity varies from person to person); otherwise we recommend that you enter UYJ=Use Your Judgment as our investigators will do a weekend day if the claimant/subject’s weekday pattern does not yield video results because of the claimant/subject’s indoor occupation and or circumstances etc. Further, requesting weekend days only may lengthen the standard turn around of the assignment simply because of the physical fact that there are only 2 weekend days in each week.)
Rush Assignment: YesNo
There is an additional $100 rush charge for all assignments that must be returned within 1 week.
Additional DVD Copy $25: YesNo
(All surveillance assignments include 1 copy of the DVD already, if you have indicated your surveillance be returned to your defense counsel, indicate here if you need a second copy sent to yourself and or the adjuster).
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
First Name:
Last Name:
Company Name:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Country:
Preferred Phone #:
Secondary Phone #:
Email Address: