2005
  
   
 
 
Online Investigation Request Form
Fill out the following form to request investigation services.

* Required Fields
Name:   *
Company Name:   *
Address:  
Address cont'd:  
City:  
State:  
Zip:  
Email Address:  
Phone Number:   *
     
 
Claim Information
Date of Loss:  
Claim Number:  
Insured:  
Turnaround:  
Required Date:  
     
 
Field Investigations:
Surveillance Needed:  
Face to Face Dependency Check Statements
PIP Elgibility / Household Insurance ----Recorded
Other ----In Person
Specify:
   
 
Internal Services
Hospital Canvass Basic Asset Search
Radiology Canvass Insurance in Household
Background Investigation Comprehensive Asset Search
Litigation Search / Prior Claims Skip Locator Search
  DMV Search
 
Claimant / Subject Data
Subject Name:  
Spouses Name:  
Street Address:  
City:  
State:  
Zip:  
Phone Number:  
Subjects DOB:  
Subjects SS#:  
Subjects D/L#:  
Gender:  
Race:  
Subject Height:  
Subjects Weight:  
Hair Color:  
Alleged Injury:  
Restrictions:  
     
 
Motor Vehicle Information
Make:  
Model:  
Year:  
Color:  
Tag #:  
State Registered:  
VIN #:  
     
 
Other Information
Budget
(for non flat-rate service)		  
Other Instructions:  
   
   
© 2005 ICU Investigations, INC.