Investigative Authorization Form

Please include as much information as possible. Items marked with an asterisk (*) are required.

Contact Information

*Report to Whom?

*Address
*Phone Fax
E-mail Address
*Type of Investigation
Your File # Case #
Type of Injury
Insured's Name
Insured's Contact
Telephone # Is contact permissible?
Date of Loss/Injury Last Day Employed
Trial Date
Written Report Deadline

Subject of Investigation

*Full Name

Street Address
City State Zip Code
Telephone Date of Birth
Sex



Race
Height Weight
Hair Color Eye Color
Glasses?



SSN Driver's License
Vehicle Color
License Plate #
Marital Status
Dependants
Last Known Employer
Contact
Occupation
Attorney

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/instructions