REFERRAL FORM
Client Information
Company:
*
Requester:
*
Email:
*
Address:
City:
State:
Zip:
Phone:
Fax:
Insured:
Video Preference:
-- Select ---
DVD
CD
VHS
Contact Preference:
-- Select ---
Email and Phone
Email Only
Phone Only
Claim Information:
Claim Number:
*
Type of Claim:
- Select -
Worker's Compensation
Liability
Auto
Property
Other
*
Date of Loss:
*
Claimant:
*
Claimant Phone:
Claimant SSN:
Address:
*
City:
*
State:
*
Zip:
*
Date of Birth:
*
Ethnicity:
Not Provided or Unknown
American Indian or Alaska Native
Asian
Black or African American
Caucasian or White
Hispanic or Latino
Multi-Racial
Native Hawaiian or Other Pacific Islander
Sex:
- Select -
Male
Female
*
Description:
0 / 900 Characters
Injury:
0 / 400 Characters
Restrictions:
0 / 400 Characters
Vehicle:
Is claimant
represented?
NO
YES
UNKNOWN
Is claimant
working?
NO
YES
UNKNOWN
Assignment Information
Assignment Type:
*
You may check more than one.
Surveillance
Background Investigation
DIGGiT (Deep Web Research)
DIGGiT 2.0
DIGGiT Extended
Hospital Canvass
Pharmacy Canvass
Clinic Canvass
Custom/Other Canvass
SIU Feasibility & Analysis
SIU State Fraud Referral
Remote Unmanned
Recorded Statement
Scene Investigation
Field Investigation
Locate
Activity Check
Wellness Check
Widow Check
Surveillance Hours:
-- Select ---
32
24
16
8
4
Canvass Count:
-- Select ---
Canvass (24)
Canvass (18)
Canvass (12)
Canvass (8)
Budget/Notes:
0 / 400 Characters
Additional Info:
0 / 450 Characters
Previous Surveillance Results:
YES
NO
Previous Surveillance Results:
0 / 2000 Characters
Receive Report By (Check All That Apply):
Online:
Email:
Reg. Mail:
Fax:
CD-ROM:
Receive Video Clips By:
Online (Via your LSLLC Customer Link Account):
Email:
For security reasons, please confirm your email address here:
*
