Surveillance Request Form

If you prefer, any or all information can be supplied via facsimile or telephone.
phone: 630-585-8430 fax: 630-978-1216

Date
Requestor	*
Phone	*
Email	*
Claimant Information
Claimant
Claim Number
Address
City
State
Zip
Phone
Alternate Phone
Date of Birth
Social Security Number
Insured
Claim Handler
Is Claimant Currently Working?	yes no
Physical Description
Sex	male female
Race
Height
Weight
Hair
Please enter other descriptive features

Other Information
Vehicle
Plate Number
Does Claimant Have an Attorney?	yes no
Injury / Restrictions
Date of Loss
Currently in Physical Therapy?	yes no
If yes, When and Where?
Special Instructions
Please include any special instructions or details not provided above.

Investigative Insights will contact you after receipt of this form. At that time we will discuss the appropriate course of action for your investigation.

*required fields

1212 S. Naper Blvd.
Suite 119-163
Naperville, IL 60540

phone: 630-585-8430
fax: 630-978-1216