Insurance Surveillance Intake Form

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InterTrace Investigations

PO Box 508

Southampton, MA 01073

 

1.888.818.8938

 

 

 

 Surveillance Experts... Worker's Comp. Surveillance...  Auto Accident Insurance Surveillance...  Disability Surveillance...  Liability Surveillance...  Insurance Fraud Surveillance...  SIU...  Insurance Fraud Investigations...  Worker's Comp. Fraud...  Disability Fraud...  Liability Fraud...  Auto Accident Fraud...

Private Investigator Robert Pac has an excellent reputation for providing high quality Investigative solutions to Insurance companies, Attorney's and the Entertainment industry since 1998. When it comes to Surveillance Investigations, he personally has over 12,000 hours of surveillance experience working Insurance Fraud, Worker's Comp., Disability, Liability, and Auto,   Surveillance Operations.

 

 

Do you Know What Your Claimant's are Doing?

We Do!

Hire the Experts and let us Show You!

We investigate your claims to determine if in fact an employee has faked or exaggerated their injuries, has unreported income or employment at a second job.

Hire the Experts and let us Show You!

Insurance Investigations Intake Form

 

                             Case Type:        Reopen Case: yes no      

Rush: yes no

 

Claim Rep: E-Mail:

 

Is there a secondary contact for this case? yes no 

If yes, Name

Phone #    Ext:      Fax #  

E-Mail

 

Insurance Company:

Address:

 

Phone: Ext: Fax#: Claim/Policy#:

 

Effective Date: Month: Day: Year:  File#:

 
Claimant's Information

Name:

Address:

City: State Zip: Zip Plus 4:

Phone: Ext: Cell Phone#

DOB Month: DOB Day: DOB Year: SSN:

DESCRIPTION:


Height:feet inches  Weight:  Hair color:

Mustache: yes no Race: Beard: yes no

Glasses: yes no        Sex M F                 Picture: yes no   

Marital Status

Does the Claimant have a known History of Violent Behavior? yes no

Date of Injury: Month: Day: Year:

Injury:

Insured:

Place of employment at time of incident:

Employer City, State, Zip:

Supervisor:

Occupation:

Phone: Ext: Okay to contact supervisor?: yes no

Claimants earning capacity:

Medical Appointments/Hearings: Month: Day: Year:

Time:

Doctor:

Location:

City/State/Zip: Phone:

Ext:

Prior Investigation: yes no Prior Investigation Month: Day: Year:

If yes, By whom?

What were the results of the surveillance

Hours Cap: Monetary Cap:

Is Claimant represented? yes no

Is physical contact OK?: yes no

Is phone contact OK?: yes no

Neighborhood canvassing?: yes no

Contact rep at end of investigation? yes no

Are there specific days for the surveillance to be conducted on yes no  

If yes, what days

If two person surveillance is needed (i.e. rural cases) is permission granted to proceed? yes no

   

 

 

Insurance Fraud Investigation

InterTrace Investigations Group works with Insurance, Self-Insured Companies, Third-Party Administrators and their Defense Counsels as an extension of your business with the sole purpose of minimizing your liabilities and resolving your investigative challenges. Our specialties include worker's compensation claims, long-term disability claims, bodily injury claims, general liability claims, etc.

 

bullet Flat Rate Surveillance
bullet Hourly Surveillance
bullet Activity Check
bullet Dependency Check
bullet Disability Check
bullet Alive & Well Check
bullet Widow/Widower Check
bullet Statements - Written or Recorded
bullet Accident Investigation
bullet

Locate/Skip Trace

We have a Guaranteed 10 day turn around time on all cases! 

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