Surveillance Assignment Sheet
Egis International, Inc.
Surveillance Assignment
We are pleased to take your Surveillance assignment...
All information provided to us will be held in the strictest confidence and used solely for the purpose of conducting the assigned investigation.
Client Information:
Your Name & Your Company or Firm Name :
Your Address:
Your Email:
Your Telephone:
Your Fax:
Case Information:
Your File / Claim No.:
Your Client / Insured / Workers Comp Employer:
Policy Number:
NAIC Number:
Date of Loss:
Subject / Claimant Information:
Subject's Name:
Address:
Telephone:
Date of Birth:
Social Security Number:
Race:
Height:
Weight:
Hair:
Eyes:
Occupation:
Employer's name and address:
Spouse & Children's names and ages:
Vehicles & License Plate Numbers:
Represented by an Attorney?
Attorney's Name & Address:
Medical Providers:
Alleged injuries and restrictions:
Has there been prior surveillance conducted?
Is Subject aware of prior surveillance?
Additional Information:
ASSIGNMENT:
Surveillance Method:
Number of Days of Surveillance:
or Financial Authorization:
Pre-Surveillance Investigation (address verification) Requested?
Due Date Requested:
Reporting Method:
Copies of Surveillance Video:
Format:
Comments / Additional Information / Specific Requests:
Copyright Egis International, Inc. 2010, 2011
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