Surveillance / Background Investigation / Activity Checks

Please fill out the following information and someone will contact you shortly.

Request Form

What is your name, company name, address and phone number?

Your Name:
Company Name:
Phone Number:
Email:
Street 1:
Street 2:
City:
State:
Zip:

What is the claimant's full contact information?

Claimant's Name:
Claimant's Phone:
Claimant's SSN?
Claimant's date of birth?
Street 1:
Street 2:
City:
State:
Zip:

Is claimant a	male or female?

Of what ethnic persuasion is this claimant?

What is the claimant's height and weight?

Height:
Weight:

Is there anything else you would like to tell us about the claimant's physical description? (i.e. hair, eyes, glasses, smoker)

Is the claimant being paid benefits at the above address?

Yes
No

Claim number?
Date of loss?

Please describe the claimant's injuries in detail:

What has led you to believe that this might be a questionable claim?

Who is insured in this matter?

What is the address of the insured in this matter?

Street 1:
Street 2:
City:
State:
Zip:

Is there anyone at the insured with whom we can confer about the claimant?

Yes
No

If yes, please provide the following contact information.

Name:
Telephone number:
Title:

Is the claimant generally home when you or the insured call?

Yes
No

What is the make, model, color and tag number of the claimant's vehicle(s)?

Make:
Model:
Color:
License Plate State:
License Plate Number:

Is claimant

single,
married,
or divorced?

If married or divorced, what is the spouse or ex-spouse's name and place of employment?

Name:
Place of Employment:

Does the claimant have any children?

Yes
No

If so, what are their ages and genders?

Does the claimant have any upcoming doctor's appointments?

Yes
No

If yes, when and where?

May we make contact with anyone in the doctor's office?

Yes
No

If yes, with whom may we confer?

What is the phone number of this doctor?

Has a rehab supplier been assigned to the claim?

Yes
No

May we contact them?

Yes
No

If yes, what is their name, company and telephone number?

Does the claimant have any upcoming court dates or hearings?

Yes
No

If yes, when and where?

Has the claimant been deposed, or is there a deposition scheduled in the future?

Deposed	Yes No
Deposition Scheduled	Yes No

If yes to either, may we contact your legal representative?

Yes
No

What is your attorney's name, firm name and telephone number?

Name:
Firm:
Number:

Has this case ever been investigated by Stop Loss, Inc. or any other firm?

Yes
No

If yes, when?	(Please fax the previous report to 678.297.9940)

Please explain any other specific instructions regarding this investigation: