Phone: 518.943.6141 Fax: 518.943.6140 Email: Acure8mail@aol.com
Request for Investigative Service
(Please fill out form completely before submitting.)
(Fields in Red are required.)
Client/Company: Representative:
Client/Company Address:
Phone: Ext: Email: Fax:
Begin Investigation as of: month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec day year Urgent/Rush Assignment? yes no
Please Conduct Confidential Investigation as Follows:
Claim Number: Date of Loss: month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec day year
Insured: Type of Claim:
Type of Investigation Requested: Select One Activity Check Surveillance Only Scene Photos Locate Witness Other If "Other", Please Specify:
Claimant Information
Full Name: First Middle Last
Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Outside U.S. Zip:
DOB: month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec day year SSN: Phone Number:
Description of Claimant:
Height: Feet Inches Weight: Hair Color: Select One Light Blond Dark BLond Light Brown DarkBrown Black Red White Grey Other Facial Hair: Select One Beard Mustache Both None Race: Select One white black hispanic asian native american/inuit other
Sex: Male Female Picture: yes no Date of Injury: month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec day year
Vehicle Information (if known): License Plate #: VIN #:
Description of injury:
Additional Claimant Information:
Prior Investigation Information
Prior Investigation: yes no If yes, date of prior investigation: month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec day year
IME/Medical Appointments/Hearings Information
IME/Medical Appointments/Hearings: month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec day year Time: AM PM
Doctor: Address:
City/State/Zip: Phone: Ext:
Additional Details for Investigation
Limit investigation? Select One Yes No Hours: Dollars :
Physical Contact OK? yes no Phone Contact? yes no Neighborhood Canvassing? yes no
Contact Representative During Investigation? yes no
Assignment:
Comments:
Please Note: Submitting this form does not constitute a contract or agreement that Accurate Investigative Services, Inc. will perform any services on your behalf. Once we receive your information, we will review your case and an agent will contact you to discuss your options. All information supplied is kept strictly confidential.
Certification and Affidavit: By submitting this online form, I hereby certify and affirm that the information supplied above is true and accurate to the best of my knowledge at this time. I understand that my knowingly supplying false or misleading information may result in my case being rejected and I will forfeit any and all funds that may be paid to the Agency pertaining to this case.
I have read and agree to the conditions stated above *