Assignment Request Form
*
required fields
Type of assignment (check all that apply)
*
Claim Investigation
Surveillance
Activity Check
Disability Interview
Database Research
Record Check
Neighborhood Canvas
Background Check
Recorded Statement
Criminal History
Other:
Type of Claim
Workers' Comp
Auto
Disability
Liability
Subrugation
Budget / Due Date
*
# of Surveillance Days
or Budget Maximum $
Secure Documents (check all that apply)
Criminal
Civil
Other
Police Report
Claim #
Additional Claim #
Assigner's Contact Information
*
Last Name
*
First Name
*
Company
*
Address
Address (cont.)
*
City
*
State
---
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip Code
*
Phone Number
Fax number
Alt Phone Number
*
E-mail Address
Preferred Method of Contact
E-mail
Telephone
Insured / Additional Information
Insured
Has file been previously investigated
Yes (by Weston Intel)
Yes (by other)
No
Is the report available
---
Yes
No
Contact
Additional Contact
Phone
Weston Intel to contact Insured
Yes
No
Previous Weston Intel File #
Additional Information or Instructions
Subject Information (Fill out as much as possible)
Last Name
First Name
Middle Name
Alias
Address
Address(cont.)
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Phone Number
Date of Loss
Social Security Number
Type of Injury
Occupation
Restrictions
DOB
Attorney
*
Is Claimant Represented
Yes
No
Attorney's Name
Address
Address (cont.)
Phone
Physical Description
Sex
Male
Female
Hair
Height
Weight
Eyes
Glasses
Race
Caucasian
Hispanic
African Am
Asian
Other
Marital Status
Single
Married
Divorced
Separated
Other Identifying Information
Vehicle Information:
Vehicle Tag #
Color
State
Doors
---
Two Door
Four Door
Make
Model
Vehicle 2 Information:
Vehicle Tag #
Color
State
Doors
---
Two Door
Four Door
Make
Model
Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility
Address
Address (cont)
City
State
---
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Phone Number
Known Appointments
Misc. Info
Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility
Address
Address (cont)
City
State
---
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Phone Number
Known Appointments
Misc. Info
Other File Information
Packaging: (choose all that apply)
Reports / Documents
Email
HardCopy
Invoices
Email
HardCopy
Video Documentation
VHS
CD-ROM
Preferred Documentation Shipping Method
Standard USPS
Overnight
Additional Report Copies to
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