Submit a Case

Specialized Investigations Online Case Submission Form

Please select "SUBMIT ASSIGNMENT" button when completed


Submitted by : (*required)


Company :


Email : (*required)


Phone : (*required)
Address :


City :


State :


Zip :



NEW ASSIGNMENT INFORMATION

Your Claim/Reference # :


Type of Investigation :


Budget (if applicable) :


Due Date :
Case Summary / Assignment Instructions : (*required)


REPORTING / BILLING INSTRUCTIONS

Report To Name/Email (if different from above) :


CC Report to Name/Email :


Mailing Address (if different from above) :


Bill to Name/Email (if different from above) # :
Comments/Instructions :


PRIMARY PARTY / INSURED INFORMATION

First Name :


Middle Name/Initial :


Last Name :


Phone # :


Cell Phone # :


Email Address :


DOB :


Driver’s License (If available) :


SSN :
Last Known Address :


Address 2 :


City :


State :


Zip :


Prior Address(es) :


Subject Physical Description (if applicable) :


Vehicle Description & License #(s) (if applicable) :


PRIMARY PARTY EMPLOYER INFORMATION

Name :


Contact Person :


Phone # :


Email :
Employer Address :


Address 2 :


City :


State :


Zip :


SECONDARY PARTY / CLAIMANT INFORMATION

First Name :


Middle Name/Initial :


Last Name :


Phone # :


Cell Phone # :


Email Address :


DOB :


Driver’s License (If available) :


SSN :
Last Known Address :


Address 2 :


City :


State :


Zip :


Prior Address(es) :


Subject Physical Description (if applicable) :


Vehicle Description & License #(s) (if applicable) :


Is the Claimant Represented? :


Attorney Information (IF Claimant Represented) :


WITNESS INFORMATION

Witness #1 :


Phone # :


Email :


Last Known Address :
Witness #2 :


Phone # :


Email :


Last Known Address :


LOSS INFORMATION (IF APPLICABLE)

Date of Loss :


Loss Location (if different from Insured/Employer) :
Loss Description :


UPLOAD DOCUMENTS HERE

Upload Document(s) to the claim :