Contact Us:
Main Office:
678-419-0555
Toll Free:
877-438-9201

Please complete the information below as completely as possible.
* indicates requred fields:

Company*: First name*: Last name*:
Address 1*: Address 2: City*:
State*: Zip*:    
Phone*: Extension: Fax:
Email:        
Desired username*: Desired password*: Confirm password*:
 
Investigation type:      
Injury: Claim Number: Budget:
           
SUBJECT INFO          
First name: Middle name: Last name:
Address 1: Address 2: City:
State: Zip: Phone:
Sex: Race: DOB:
SSN: Height: Weight:
Married? Spouse name: Dependents:
Do you have a photo of the claimant?      
           
INSURED/EMPLOYER INFO          
Company: Address 1: Address 2:
City: State: Zip:
Contact: Phone: Extension:
Can we call the contact?        
           
CLAIMANT VEHICLE INFO          
Do you have vehicle information on the claimant?    
Year: Make: Model:
Color: Tag number: State of issue:
           
UPCOMING APPOINTMENTS          
Does the claimant have any upcoming appointments?    
Office: Doctor: Type:
Address 1: Address 2: City:
State: Zip: Phone:
Appointment date: Appointment time:    
           
CLAIMANT REPRESENTATION          
Is the claimant represented?      
Firm: Attorney: In service of:
Address 1: Address 2: City:
State: Zip: Phone:
Depo date: Depo time:    
           
DEFENSE ATTORNEY          
Do you have a defense attorney on this claim?      
Firm: Attorney: In service of:
Address 1: Address 2: City:
State: Zip: Phone:
Depo date: Depo time:    
           
Do you have previous reports from another investigative agency?    
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