| Date |
| Claim Number |
| Date of Loss |
| Insured |
| Date Needed |
| Arbitration/Trial/Hearing Date |
| Subject |
| Social Security Number |
| Address |
| City |
| Zip Code |
| Phone Number |
| Date of Birth |
| Sex |
| Race |
| Marital Status |
| Spouse's Name |
| Subject's Vehicle |
| Type of Claim |
| Physical Description |
| Alleged Injury |
| Physical Restrictions |
| Investigation Purpose |
| Special Instructions |
| If two crews are needed (i.e. rural cases), is permission granted to proceed? Yes No |
| Has previous surveillance been performed? Yes No |
| Does the claimant have a history of violent behavior? Yes No |
| Are you a first time client? Yes No |
| Has D.I.G's billing procedure been explained? Yes No |
| Are there specific days for the surveillance to be conducted? Yes No |
| What days? |
| Restrictions: Day or Dollar Limit? |
|
| Copyright 2006-2007 by DEFENSE INVESTIGATORS GROUP |