Higgins & Associates Investigative Services  

 

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See home page www.investigations.net for information
 

Team Investigations Online Investigation Request Form is secure. Please enter the information and click "Submit" to send your request.  To return to our home page, please click here.

You will receive a call once we receive your request. If you have any questions about how to fill out the form, please call us at 1-800-555-3246 for assistance. Thank you for your business!


Use Your Customer # 
to fast fill form             
*Requester:
*Company:
*Address:
*City:
*State:
*Zip:
*Phone:
Email:
Toll Free:
FAX:
How did you hear of  us?:

*Type of Claim?:

*Date of Loss:

*Insured:

*Claim Number:
Claimant/Subject Information
*Subjects Full Name:
*Address:
*City:
*State: <>
*Zip:
Phone:
DOB:
SSN:
Race:
Hair Color:
Height:
Weight:
Sex:
Marital Status:
Spouse's Name:
Special Physical Characteristics
(i.e. glasses, beard):
Occupation:
Hobbies:
Alleged Injury:
Restrictions:
Children/Ages:
Vehicle 1(Make/Model): Tag Number:
Vehicle 2(Make/Model): Tag Number:

Employer/Rehab/Physical/Attorney Information
Subject's Employer:
Employer Contact:
Employer Address:
City: State: <> Zip:
Employer Phone:
Rehab Company:
Rehab Contact:
Rehab Address:
City: State: <> Zip:
Rehab Phone:
Physician:
Physician Address:
City: State: <> Zip:
Physician Phone:
Subject's Attorney:
Attorney's Address:
City: State: <> Zip:
Wage Loss Paid: Weekly Amt:
Exposure:
Address Sent:
City: State: <> Zip:
Prior Investigations:
Any known appts.,
hearings, etc.:

Specific Instructions/Objectives
Why are you assigning surveillance?:
Client Objective 1:
Client Objective 2:
Client Objective 3:

Authorization (Select at least one)
*Budget (Days/Amt):
Extend Surveillance 12 hrs/per day
Standard Surveillance 10 hrs/per day
Limited Surveillance 8 hrs/per day
Background Check (civil/criminal/asset)
Activity Check
Other

Packaging (Choose all that apply)
*Report: TeamTrak     Email     Hard Copy
*Photo Snippets: TeamTrak     Hard Copy
*Invoice: Email     Hard Copy
*Video: TeamTrak VHS CD-ROM () Real Player () MPEG
Other:


Due Date
*Due Date


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