Surveillance and Activity Request
We have the ability to deploy GPS tracking systems for vehicles for fleet monitoring.
Firm
Attention
Address
Date
City, State, Zip
Court
Telephone
Case No
Ext./Direct Line
Case Title
Your Fax No.
Claim/File No.
Your E-mail
Date of Loss
PLEASE NOTE ANY SPECIFIC SERVICE REQUIREMENTS
Please check the services required:
Video Surveillance
Activities Check
Other
Date
Completion Deadline
Trial or Hearing Date
Subject
Social Security No.
Address
City
State
Zip
Phone
If two crews are needed (i.e., rural cases), is permission granted to proceed?
Yes
No
Physical Description
Date of Birth
Sex
Race
Marital Status
Spouse’s Name
Subject’s Vehicles
Alleged Injury
Physical Restrictions
Claim #
Date of Loss
Insured
Type of Claim
Previous Surveillance Performed?
Yes
No
(If “Yes,” attach report.)
Does the claimant have a history of violent behavior?
Yes
No
If “Yes,” two crews are necessary
What is the purpose of the investigation?
Special Instructions:
Are there specific days for the surveillance to be conducted?
Yes
No
If “Yes,” What days?
Restrictions: Day or $ Limit
Client
Company
Address
City
State
Zip
Phone #
FAX
E-Mail
Internet
CompuServe
AOL
Other
Is there a secondary contact for this case?
Yes
No
(If “Yes,” please fill in the form below:)
Client
Phone #
FAX
E-Mail
Internet
CompuServe
AOL
Other
Are you a full-time client?
Yes
No
Referred by
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