ASSIGNMENT FORM

Video Surveillance              Activities Check                    Other

Your Name	Email
Company	Phone Number
Address	Fax Number
City	Zip Code

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?

Is there a secondary contact?
Your Name	Email
Company	Phone Number
Address	Fax Number
City	Zip Code
Referred by

Copyright 2006-2007 by DEFENSE INVESTIGATORS GROUP