What kind of service are you requesting?
What is your allotted budget or number of days?
City, State, Zip
As our client, please describe your main objective in this case.
What is your preferred method for receiving your report?
---Paper Report and video on DVD (if available)Report and video on CD (if available)
Is Claimant currently receiving payments
If yes, please note where payments are sent
Date of Birth
Social Security Number
Height, Weight, Race, Hair Color
Type of Injury
How and where did injury occur?
Ok to contact insured?