INSURANCE OR WORKERS COMP INVESTIGATION REQUEST

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*IS REQUIRED INFORMATION
* Office you wish to contact:
(YOU MUST CHOOSE AN OFFICE OR YOUR REQUEST WILL NOT BE DELIVERED!)
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Charleston
Columbia
Greenville
Myrtle Beach
CLIENT INFORMATION
* NAME
* E-MAIL ADDRESS
ADDRESS
CELL PHONE
CAN WE CONTACT YOU ON YOUR CELL?
CAN WE LEAVE A MESSAGE ON YOUR CELL?
WORK PHONE
CAN WE CONTACT YOU AT WORK?
CAN WE LEAVE MESSAGE AT WORK?
DO YOU HAVE AN ATTORNEY?
ATTORNEY NAME
OPPOSING ATTORNEY NAME
CLAIMANT INFORMATION
SUBJECT OF INVESTIGATION FULL NAME
ADDRESS (IF DIFFERENT FROM ABOVE)
AGE
DOB
RACE/SEX
HEIGHT
WEIGHT
HAIR COLOR
HAIR LENGTH
GLASSES
TATTOOS/SCARS
SSN
SUBJECTS VEHICLE
TAG NUMBER
DOES ANYONE ELSE DRIVE THIS VEHICLE?
VEHICLE COLOR
CLAIMANT EMPLOYER
ADDRESS
WORK HOURS
DAYS OFF
LUNCH HOUR/BREAKS
BEHAVIOR CHANGES IN SUBJECT
DOES SUBJECT HAVE ANY REASON TO BE SUSPICIOUS OF THE INVESTIGATION?
CLAIMANT'S FRIENDS / ADDRESSES
CLAIMANT'S FAVORITE RESTAURANTS / HANGOUTS / HOBBIES
OTHER PERTINENT INFORMATION
REFERRED BY
IF ATTORNEY OR OTHER PLEASE SPECIFY

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