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Assignment Request
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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
* 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
Is the report available
Contact
Additional Contact
Phone
Weston Intel to contact Insured
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
Zip Code
Phone Number Date of Loss
Social Security Number Type of Injury
Occupation Restrictions
DOB
 
Attorney
*  Is Claimant Represented
Attorney's Name
Address
Address (cont.)
Phone
 
Physical Description
Sex Hair
Height Weight
Eyes Glasses
Race Marital Status
Other Identifying Information
 
Vehicle Information:
Vehicle Tag # Color
State Doors
Make Model
Vehicle 2 Information:
Vehicle Tag # Color
State Doors
Make Model
 
Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility
Address
Address (cont)
City State
Zip Code  
Phone Number
Known Appointments
Misc. Info
Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility
Address
Address (cont)
City State
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