To refer a case for investigation:

Please complete the following referral form and when ready, hit the submit button at the bottom. If you need immediate assistance; have further instructions; or have questions, please call us at 800.233.0417.

INSTRUCTIONS: To navigate from one blank to the next, please press the "Tab" button on your keyboard or use your mouse to click the appropriate box. When finished completing the form, check the box at the bottom of the page and click the "Submit" button to submit your request. Thank you!

CUSTOMER INFORMATION
ALL CUSTOMERS
YOUR COMPANY:
FIRST NAME: *
LAST NAME: *
EMAIL: *
NEW CUSTOMERS
PHONE:
CELL:
ADDRESS:
CITY:
STATE:   ZIP:


CASE DETAILS
Workflow: *
State: *
Investigation Type: *
DATE OF LOSS / INJURY / DISABILITY: (MM/DD/YYYY)
BUDGET HOURS:
INSURED:
INSURED CONTACT:
CLAIM NO.
INSTRUCTIONS: (reasons for investigation and instructions)
SPECIAL REQUESTS: (dates for surveillance, medicals etc.)
UPDATES REQUIRED:


SUBJECT DETAILS:
 
FIRST NAME:
LAST NAME:
ALIAS NICKNAME:
PHONE:
CELL:
ADDRESS:
CITY:
STATE:   ZIP:
DOB:
SSN:
GENDER: Male Female
RACE:
HEIGHT:
WEIGHT:
BUILD:
HAIR:
MARITAL STATUS:
SPOUSE NAME:

CHILDREN NAMES & AGES:
ADDITIONAL DESCRIPTION:
INJURY:
EMPLOYER:
OCCUPATION:
REPRESENTED: YES    NO
ATTORNEY DETAILS:
CLAIMS HISTORY
Receiving Benefits
Amount of Benefit
DESCRIPTION OF LOSS / ACCIDENT:
KNOWN VEHICLES:
(List Make, Model, Year)		 VEHICLE 1

VEHICLE 2

VEHICLE 3
DOCTOR 1
DOCTOR 2
DOCTOR 3
PREVIOUS SURVEILLANCE
UPLOAD DOCUMENTS

Yes, I have reviewed the information I am submitting and it is accurate to the best of my knowledge


Thank you for taking the time to complete this form.Please click the "Submit" button if you are finished.

Please only press the SUBMIT button once and wait for the submission to process and you will receive a confirmation.
It may take up to 2 minutes for the case to be created and for us to display your case number and confirmation