Surveillance Assignment Sheet
Egis International, Inc.
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.
Your Name & Your Company or Firm Name :
Your Client / Insured / Workers Comp Employer:
Subject / Claimant Information:
Employer's name and address:
Spouse & Children's names and ages:
Vehicles & License Plate Numbers:
Represented by an Attorney?
Attorney's Name & Address:
Alleged injuries and restrictions:
Has there been prior surveillance conducted?
Is Subject aware of prior surveillance?
Number of Days of Surveillance:
or Financial Authorization:
Pre-Surveillance Investigation (address verification) Requested?
Copies of Surveillance Video:
Comments / Additional Information / Specific Requests:
Would you like on line Case Status Updates with Video Clips?
Copyright Egis International, Inc. 2010, 2011, 2012, 2013, 2014, 2015