CSSI Investigative Services Request Form
800-239-2774(Toll Free) 205-987-9363(Fax) www.cssi.net
Client
Required Fields in Red
Date:
Your File No.
:
Client:
CSSI File No.:
Company:
Telephone:
E-Mail:
Type Claim:
Workers' Comp
General Liability
Death/Disability
Special Investigation
Subrogation
Type of Investigation(s):
Surveillance
Background
Accident/Statement
Locate
Type of Investigation(s): cont...
Claimant Interview
Wellness Check
Activity Check
Dependency Follow-up
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:
Insured
Company/Insured:
Address:
City,State:
Zip:
OK to contact:
Contact Person:
Telephone:
Additional Contact Person:
Telephone:
Subject
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:
Hgt:
Wgt:
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:
Other
Known Appointments?
Date:
Time:
Location:
Receiving Benefits?
If yes, How (mail, pick up, etc.) and Location:
Represented by Attorney?
Plaintiff Attorney Name:
Address:
Litigation?
Defense attorney Name:
Address:
Notes or additional information:
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