Assign A Case

Insured:

Weight:

Specific Instruction/Objectives/Reason for Investigation/Additional Information:

Claim/File Number:

Client's Phone Number: *

Children/Ages:

Current Employment (if applicable):

Client's Address: *

Phone Number:

Is Claimant Represented? (Attorney's Name):

Spouse's Name:

Claimant's Name: *

Sex: *

Additional Comments:

Marital Status:

Thank you for your business. An investigator will contact you within 24 hours of case assignment.