CSSI Investigative Sercies Reqeust Form

CSSI Investigative Services Request Form

800-239-2774(Toll Free) 205-987-9363(Fax) www.cssi.net

Required Fields in Red

Date:			Your File No.:
Client:			CSSI File No.:
Company:			Telephone:
			E-Mail:

Type Claim:

Workers' Compensation

General Liability

Death/Disability

Special Investigation

Subrogation

Type of Investigation(s):

Surveillance

Background

Dependency Follow-up

Accident/Statement

Locate

Specific Instructions/Dates:

Prior Investigation?

If yes, last date(s) conducted:

Problems or Confrontation:

Authority/Limit:

Date(s) of Loss:

Type of Loss:

Special Billing Instructions:

Company/Insured:

Address:

City,State:

Zip:

OK to contact:

Contact Person:

Telephone:

Additional Contact Person:

Telephone:

Subject's Last Name:

First Name:

Middle:

Last Known Address:		City:		State:		Zip:
Other Known Address:		City:		State:		Zip:

Current Telephone(s):

Other Telephone(s):

Date of Birth:

Age:

SSN:

Drivers License #:

State:

Race:

Sex:

Height:

Weight:

Build:

Hair:

Length:

Glasses:

Other Features:

Maritial Status:

Reside with subject:

Dependents?

Names/Ages:

Reside with subject:

Job Type/Duties:

Known Vehicles

State & Tag #:

Description of Vehicle:

Known Vehicles

State & Tag #:

Description of Vehicle:

Known Appointments?

Date:

Time:

Location:

Receiving Benefits?

If yes, How (i.e. mail, pick up, etc.) and Location:

Represented by Attorney?

Plaintiff Attorney Name:

Address:

Litigation?

If yes, defense attorney name:

Address:

Notes or additional information: