Company		Phone
Requestor ------------  Email	* required	Mailing  Address
Date of Assignment		Due Date
Type of Assignment	Surveillance Wellnes Check Activity Check Background SIU Investigation Other	Report Format	Online Login Email PDF USPS Standard FedEx Express UPS Other
Insured		Insured Address
Insured Contact		Insured Phone
Claim #		Type of Claim	Workers Compensation Personal Injury Home Owners Auto Other
Claimant's Name		Claimant Address
Home telephone Cell telephone		Work phone Other
DOB		SSN
Race	White Black Hispanic Asian Other	Male Female	Hair Black Brown Blonde Red Highlights Other Short Medium Long Shaved Balding
Height		Weight
Characteristics		Vehicle Information
Alleged Injury		Scheduled appointments
Represented by Attorney	Yes No	Attorney's name
Case Budget		Additional Case Notes