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New Assignment for Specialized Investigations
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Date of Loss:
Type of Investigation:
Budget (if applicable):
Due Date:
Assignment Instructions:
Characters left:
Reporting / Billing Instructions
Report to Name/Email (if different from above):
CC Report to Name/Email (if applicable):
Mailing Address (if different from above):
Bill to Name/Email (if different from above):
Other Comments / Instructions:
Characters left:
Primary Party / Insured Information
First Name:
Middle Name / Initial:
Last Name:
Phone #:
Alternate Phone #:
Email:
DOB:
Driver's License #:
SSN:
Street Address:
Address 2:
City:
State:
Zip:
Prior Address(es):
Characters left:
Subject Physical Description:
Characters left:
Vehicle Description:
Characters left:
Primary Party Employer Information
Company Name:
Contact Person First Name:
Contact Person Last Name:
Phone:
Email:
Address 1:
Address 2:
City:
State:
Zip:
Secondary Party / Claimant Information
First Name:
Middle Name/Initial:
Last Name:
Home Phone:
Cell Phone:
Work Phone:
Email:
Date of Birth:
Driver's License #:
SSN:
Street Address:
Address 2:
City:
State:
Zip:
Prior Address(es):
Characters left:
Injury:
Characters left:
Claimant Physical Description
Height:
Weight:
Eye Color:
Hair Color:
Vehicle Description:
Characters left:
Is Claimant Represented?
Attorney Info (if Represented):
Witness Information
Witness 1 - First Name:
Witness 1 - Last Name:
Witness 1 - Phone:
Witness 1 - Email:
Witness 1 - Address 1:
Witness 1 - Address 2:
Witness 1 - City:
Witness 1 - State:
Witness 1 - Zip:
Witness 2 - First Name:
Witness 2 - Last Name:
Witness 2 - Phone:
Witness 2 - Email:
Witness 2 - Address 1:
Witness 2 - Address 2:
Witness 2 - City:
Witness 2 - State:
Witness 2 - Zip:
Loss Information
Loss Description:
Characters left:
Loss Location - Address 1:
Loss Location - Address 2:
Loss Location - City:
Loss Location - State:
Loss Location - Zip:
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