ASSIGNMENT REQUEST FORM

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.

Please complete fields in "red".
Type of Case/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:
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: Photo?
Marital Status: # of Dependents:
Employer: Employer Address:
Employment Status:Time/Days:
Work Contact:Work Phone:
Previous Surveillance? 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:
Additional Information
Please specify any additional information that may be relevant to this case.
CONTACT US!
Securac Investigations
615 S Broadway
Tyler, TX 75701
Office:
903-592-1155
1-877-592-1155
Fax:
1-888-296-0290
Company License:

C-10783
lloydyoung@securac.com