Your Name:   
Your Company Name:  

Address:
City, State, & Zip:

Phone #      Ext #:   
Email: 

How were you referred to our office?:  Choose a referral source Search Engine Another Client OPIA PI Resource Locator Casualty Adjusters Guide The PI Mall Tulsa Claims Association Oklahoma City Claims Association Your material send to our office Phone Book Other source             
Please specify:

How would you like us to contact you?: Choose Contact Method Just Send Reports and Video upon completion Call with daily Updates E-mail Daily Updates Email Final Report and Mail Video to me Call for further Authorizatio I will contact your office
Please specify:

What is the Nature of this Investigation?  Choose Type of Investigation Workers Compensation Auto PIP Disability Personal Injury Other Insurance Product Liability Interview witness Collection Investigations Other Specified Below
Please specify:

Authorized for Choose Authorization Option 4 Hours (Activity Check) @ $60.00 per hour 1 day @ $60.00 per hour 2 days @ $60.00 per hour 1 week (5 days, 8-10 hours per day) @ $2200.00 2 weeks (10 days, 8-10 hours per day) @ $4000.00 Other Specified Below
Specific Authorization:
Authorized by:  

Specific day for surveillance?  
For    Choose Type Doctor Appointment Court Appearance Deposition Physical Therapy Appt Other Specified Below
Please specify other or location:

CLAIMANT INFORMATION

Your Claim Number:   

Claimant’s Name:
Home Address:
City, State & Zip:

Daytime Phone          Night-Phone 
Cell Phone         Pager:

Employer:   
Work  Address:
City, State & Zip:
Phone:

Type of Job/Duties 
Usual Work Hours    Currently working? Choose an answer Yes No I am not sure

Subject's Description & Personal Information: 

Age  Date of Birth   Sex     Choose an answer Male Female Unknown
Race    Height    Weight  
Hair Color    Hair Style     Facial Hair?
Glasses?   Contacts?    Other

Social Security Number  
Driver's License #   State

Does the Subject have any Known Scars or other Identifying marks or behavioral
habits that we should be aware of?

What type of vehicle(s) does the Subject drive?
   License #
   License #
   License #
   License #

Subject's Friends, Hangouts:
Please provide names and addresses of friends of the subjects...Places he/she might
go to hangout.  Free form is provided for your input.

Place 1.

NOTE:  Do not type in more information than can be seen on the screen as it will
not print out!

Place 2

Place 3.

Place 4.

IS THE SUBJECT AWARE OF THIS INVESTIGATION? Choose an answer Yes No I am not sure
If yes or not sure please explain: 
 

DETAILED EXPLANATION OF WHAT YOU WOULD LIKE US TO DO:

INJURY INFORMATION:

Date of Injury?   Body Part(s)
How the injury occurred

Treating Physician Name
Next Appt?  
Address
Restrictions?    

Physical Therapy Facility
Next Appt?  
Address
How often?   

 

ATTORNEY INFORMATION:

Is the Claimant Represented?  Choose an answer Yes No I am not sure  
Name of attorney?
Phone Number?  
Address:    

Are you Represented?  Choose an answer Yes No Not sure
Name of attorney?
Phone Number? 
Address     

Any other information about this case? 

OTHER INFORMATION THAT WOULD BE HELPFUL TO HAVE:
Form 2, Form 3 or any forms regarding this case, accident report, physician notes, photograph of the Claimant, and any other information that you might have on the Claimant.   

REMEMBER: 
What you already know is valuable, only if you communicate it to us.  If you
have information that would be helpful to the investigation, you can save money
by providing that upfront. 

You may print out the form and fax to 405)282-1329 OR
click on the "Submit Form" button to E Mail the information.

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