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Assignment Request
Assignment Request
This form is for agency use only.
1. Assignment Details
Request For:
*
Activities Check
Alive and Well
Asset Check
Background Check
Deposition/Hearing
Documents
Employment Check
Investigation
Mediation
Medical Canvass
Residency Check
Social Media Search
Subpoena
Surveillance
Transcription
Video
Request Date
Auth Limit (Budget)
Rush
No
Yes
Due Date
2. Your Information
Company Name
*
Assigned By
*
Address
*
City
*
State
*
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Phone
*
Fax
Claim Number
*
Email Address
*
3. Insured Information
Insured
*
Insured Contact
Address
City
State
*
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone
4. Subject Information
Subject Name
*
Address
City
State
*
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone
Sex
*
---
Male
Female
Unknown
Date of Birth
(mm/dd/yyyy)
SSN
Race
Weight
Height
Hair Color
Eye Color
Marital Status
---
Single
Married
Widowed
Widower
Spouse
Children
Injury
Occupation
Subject's Attorney
Subject Work Status
*
---
Yes - Light Duty
Yes - Full Duty
No
Unknown
Subject's Work Schedule
Subject's Upcoming Appointments
Add Additional Subject
5. Claim Details
Claim Type
*
---
Workers Compensation
Liability / Auto
Other
Date of Loss
(mm/dd/yyyy)
Location of Loss
6. Additional Details
Additional Notes and Remarks
Attachments
You may upload files with the request:
File #1:
File #2:
File #3:
File #4:
Trap
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