New Surveillance/Background Investigation/Special Investigations Form

If you have a client access user ID and password, please click here to log in to Client Access and submit your request from there. If not, please fill out and submit this form and a user ID and password will be assigned to you.

You will have the option to add additional subjects and upload attachments after submitting this form.

Your Information

* - required fields
Name: * Phone: *
Company: * Toll free:
City: * Fax:
E-mail: * Position: *
Principal Company: * File #:
Principal City: * Policy Number:
Principal Toll Free: Principal Phone:
Principal Examiner/Adjuster: Principal Fax:
Independent Adjusting Firm: CI File No.: (Where Applic.)
Independent Adjuster: Claim Department: *

Loss Information

Insured Name (first/last):
Date Of Loss: (mm/dd/yyyy)
Type of Loss:
 

Fire

Theft

Other

   
Vehicle:

Property:

 
Circumstance of Loss:

Investigation Requested

Surveillance: Consecutive Days:
Bankruptcy Search: Financial Background: Present Employment:
Locate: Court Search: Previous Employment:
Previous Claims: Lien Search: W.C.B. Inquiry
Investigative Services: (For IS Services Only)    
Assignment Limit $: Province: *
(where investigation will take place)
Video Format:
Specific Investigation Instructions:

Subject Information

*Note: If there are 2 or more Subjects, complete assignment form and click Submit Assignment. You will be prompted to add another Subject.
Name: (first/last) * Phone:
Address: Work Phone:
  Cell Phone:
 
City: Province: *
Postal Code: SIN:
Physical Description:    
Spouse: Gender:
Vehicles: Date Of Birth: (mm/dd/yyyy)
VIN: Photos:
Driver Lic #: Bankruptcy Police Report:
Occupation:      
Employer:
  Name
Physio:
Doctor:
Clinic:
Lawyer:
Reported Injury:
Further Subject Information: