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Investigation Assignment Request
Toll-Free: (888) 811-3253 Telephone & Fax: (805) 579-0641
P.O. Box 1696, Simi Valley, CA 93062-1696

Client Information:
Name:_______________ Company:_______________ Claim No.:____
Address:_______________________________ Phone No.:__________
Work Address:____________________________ Phone No.:________
Other Address:____________________________ Phone No.:________

Attorney Information
Name:_______________________ Contact:______________________
Address:________________________________ Phone No.:_________

Subject Information:
Name:_______________________ SSN:_______________ DOB:______
Race:_______ Height:______ Weight:______ Eyes:______ Hair:______
Address:_________________________________ Phone No.:__________
Prior Address:________________________________________________
Job/Address:_______________________ Occurrence Date:___________
Injury/Loss:__________________________________________________
Other Information:_____________________________________________
Attorney:____________________________________ Phone No.:_______

Investigation ( ) Asset Search ( ) Background Investigation ( ) Surveillance/ Undercover ( ) Missing Person ( ) Personal Injury ( ) Process Service ( ) Criminal ( ) Other______	Interview/Statement ( ) Employee ( ) Co-Workers ( ) Witness(es) ( ) Employer ( ) Supervisor ( ) Doctor(s) ( )Third Party ( ) Police Officer(s) ( ) Other________	Obtain ( ) WCAB Records ( ) Wage Records ( ) Medical Records ( ) Medical Authorization ( ) Physical Evidence ( ) Police Reports ( ) Death Certificate ( ) Other_______	Rush Need by:_________ (Date)
			Call Before Commencing Assignment Phone:_____________

Special Instructions:
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