Please use this form to describe your investigative request and give us your information. By doing this online, it will give us a head start understanding your needs when we speak to you. Type of Assignment/Claim Worker's Comp Activities       Check Background       Check Locate Liability Surveillance Statement(s) Investigation Other Budget: Other comments: Client Information Company Name: Client Name: Company Address: City: State: Zip Code: Phone: Fax: Your Email: SIU Number: Claim Number: * Mailing Instructions other than Client Company Name: Client Name: Company Address: City: State: Zip Code: Phone: Subject Information Claimant/Subject Name: Date of Loss: Primary Address: Primary City: Primary State: Primary Zip Code: Primary Telephone: Secondary Telephone: Cell Phone: DL #: SSN#: DOB: Height Weight Race: Hair Eyes Facial Glasses: YesNo Photo? YesNo Marital Status: MarriedSingleSeparatedDivorced # of Dependents: Work: Work Address: Work Status: OffLight DutyNot Applicable Time/Days: Work Contact: Work Phone: Previous Surveillance? YesNo If Previous Surveillance Yes: When? Comments: Injury/Loss Date of I/L: Nature (MVA,SLIP/FALL,ETC): Description of I/L: Doctor's Name: Address: City: State: Doctor's Zip: Doctor's Phone: Next Scheduled Appointment: Second Doctor's Name: Address: City: State: Doctor's Zip: Doctor's Phone: Next Scheduled Appointment: Additional Information Additional Information (please include any additional information you believe is relevant to this case) | About ISIS | How ISIS Works | What ISIS Offers | | Services | Pre-employment Services | Equipment | ISIS Offices | | Billing Points | ISIS Charges | Home | E-mail | Assignment Request | ©1999-2007 ISIS Investigations, Inc. , P.O. Box 577, Tyler, Texas 75710 (903) 533-1712 Phone   (903) 533-1713 Fax   email: info@isisinv.com Maintained & Powered © Web Fox Studio