Service Request Form

To request service, complete the following form and click the "Submit" button. Your information will be sent via e-mail to our customer service department. You may also place an assignment by calling us at 570-714-4116. All service requests submitted with this form will be confirmed via e-mail or telephone.

Please provide the following for all assignments:
Date of Request: 
Requested by (Your Name):
Your e-mail address: 
Your Phone Number w/area code: 
Your Company Name: 
Address: 
City: 
State & Zip: 
Service(s) Required: 
(Service examples: Surveillance, Investigation, Activity Check, Recorded Statement, Photos, Data Base Search, Other, etc.)
Budget/Time Allocation: 
Your File No.: 
Insured Company or Name: 
Contact Name at Insured: 
Phone # of Contact at Insured: 

Please complete the following for surveillance assignments 
and activity checks 
(including domestic cases)

Subject Name: 
Subject Alias: 
Subject Phone w/Area Code: 
Subject Current Address: 
Subject Previous Address: 
Subject’s Social Security #: 
Subject’s Date of Birth: 
Subject’s Employer: 
Subject’s Occupation: 
Injury: 
Date of Injury:

DESCRIPTION
Race: 
Sex: 
Height: 
Weight: 
Hair: 
Glasses: 
Facial Hair: 
Build: 
Identifying Marks: 
Peculiarities (canes, crutches, limps, etc.): 
Marital Status: 
Spouses (Names, etc.) :
Dependents (Names, etc.): 
Is Subject Represented? :  Yes    No
If yes, please provide name, telephone # & address of attorney:
Treating Physician: 
Physician Telephone#: 
Physician Address: 
Scheduled Appts/Therapy:   Yes    No
Address of Appt/Therapy: 
Vehicle Info: 
Other Information & Special Interests: 
Was Subject investigated by another agency?   Yes  No
Name, Date, copies of previous report’s available? Yes No

Please complete the following (were applicable) for all recorded statements, photographs, diagrams, etc.
Date of Accident: 
Location of Accident: 
Service (s) Required: 
(Service Example: Recorded Statement, Photographs, Diagrams, etc.)
Special Requests/Instructions: 
Records Requested: 
(courthouse records, vehicle info, data search, etc.)

Information for recorded statement interviewee #1
Role in accident: 
(Insured, operator, passenger, witness, etc.)
Name: 
Home Phone w/Area Code: 
Work Phone w/Area Code: 
Address: 
Is Interviewee represented?  Yes    No
If yes, please provide name and address of Attorney: 
Any additional comments or information: 

Information for recorded statement interviewee#2
Role in accident: 
(Insured, operator, passenger, witness, etc.)
Name: 
Home Phone w/Area Code: 
Work Phone w/Area Code: 
Address: 
Is Interviewee represented?  Yes   No
If yes, please provide name and address of Attorney: 
Any additional comments or information: 

Information for recorded statement interviewee#3
Role in accident: 
(Insured, operator, passenger, witness, etc.)
Name: 
Home Phone w/Area Code: 
Work Phone w/Area Code: 
Address: 
Is Interviewee represented?  Yes   No
If yes, please provide name and address of Attorney: 
Any additional comments or information: 

Information for recorded statement interviewee#4
Role in accident: 
(Insured, operator, passenger, witness, etc.)
Name: 
Home Phone w/Area Code: 
Work Phone w/Area Code: 
Address: 
Is Interviewee represented?  Yes   No
If yes, please provide name and address of Attorney: 
Any additional comments or information: