Assign/Request Case Complete the form below to get started working with a private investigator on your case. Case Assignment Form Claim# Date MM slash DD slash YYYY Services Surveillance Skip Trace / Location Activities Check Statement / Interview Background Check Liability Employment Check WC Other Subject InformationName First Last PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State SSN City of Birth State of Birth Date of Birth MM slash DD slash YYYY Driver’s License Number Description of SubjectAttach PhotoMax. file size: 50 MB.Hair Height Weight Eye Color Spouse Name Dependants Vehicle Make Vehicle Model Vehicle Color Vehicle Tag Number Occupation Employer Alleged Injury Date of Loss MM slash DD slash YYYY Insured / Address Treatment Restrictions Prior Investigation / Surveillance Yes No (if Yes, please explain)ExplainSpecial Instructions Client InfoAuthorized Limits:(Required) (Includes Expenses)Total Number of Days(Required) Client Name(Required) First Last Email Address(Required) Main Phone Number(Required)Company Name Fax/Other Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Website CommentsThis field is for validation purposes and should be left unchanged.