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INSURANCE OR WORKERS COMP INVESTIGATION REQUEST
Request Service Myrtle Beach or Charleston Area
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Email
*
Your email
WHICH OFFICE DO YOU WISH TO CONTACT?
*
Myrtle Beach
Charleston
CLIENT INFORMATION
NAME
Your answer
EMAIL (if different from above)
Your answer
ADDRESS
Your answer
CELL PHONE
*
Your answer
CAN WE CONTACT YOU ON YOUR CELL PHONE?
*
Yes
No
CAN WE LEAVE A MESSAGE ON YOUR CELL PHONE?
*
Yes
No
WORK PHONE
*
Your answer
CAN WE CONTACT YOU AT WORK?
*
Yes
No
CAN WE CONTACT YOU AT WORK?
*
Yes
No
CAN WE LEAVE A MESSAGE AT WORK?
*
Yes
No
DO YOU HAVE AN ATTORNEY
Yes
No
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ATTORNEY NAME
Your answer
OPPOSING ATTORNEY NAME
Your answer
CLAIMANT INFORMATION
SUBJECT OF INVESTIGATION FULL NAME
*
Your answer
ADDRESS (IF DIFFERENT FROM ABOVE)
Your answer
AGE
Your answer
D.O.B.
MM
/
DD
/
YYYY
RACE/SEX
Your answer
HEIGHT
Your answer
WEIGHT
Your answer
HAIR COLOR
Your answer
HAIR LENGTH
Your answer
GLASSES
Your answer
TATTOOS SCARS
Your answer
SSN
Your answer
SUBJECT VEHICLE
Your answer
SUBJECT VEHICLE TAG NUMBER
Your answer
DOES ANYONE ELSE DRIVE THIS VEHICLE?
Yes
No
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DO YOU HAVE ACCESS TO THE SUBJECTS VEHICLE?
Yes
No
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VEHICLE COLOR
Your answer
CLAIMANT EMPLOYER
Your answer
CLAIMANT EMPLOYER ADDRESS
Your answer
SUBJECT WORK HOURS
Your answer
DAYS OFF
Your answer
LUNCH HOUR/BREAKS
Your answer
BEHAVIOR CHANGES IN SUBJECT
Your answer
DOES SUBJECT HAVE ANY REASON TO BE SUSPICIOUS OF THE INVESTIGATION?
Your answer
CLAIMANT 'S FRIENDS / ADDRESSES
Your answer
CLAIMANT 'S FAVORITE RESTAURANTS / HANGOUTS / HOBBIES
Your answer
OTHER PERTINENT INFORMATION
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REFERRED BY
Website
Attorney
Word-of-Mouth
Friend
Other
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IF ATTORNEY OR OTHER PLEASE SPECIFY
Your answer
Submit
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