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SUBMIT A CASE

Your First Name and Last Name*

Email*

Phone*

Subject/Claimant First Name and Last Name*

File Number (if applicable):

Subject/Claimant's Date of Birth:

Subject/Claimant's Last Known Address:

Subject/Claimant's Phone Number and Email/ Social Media Handle:

Subject/Claimant's Description:

Date of Loss, Injury, and Physical Restrictions (if applicable):

Upcoming Doctor Appointment Details (if applicable):

Doctor Name, Address, Phone Number and Appointment Date/Time

Insured/Employer Details (if applicable):

Insured/Employer Name, Address, Phone Number and / or Email

Assignment Familiarity

Type of Case/File

Surveillance Number of Days (if applicable):

Additional Research/ Detailed Instructions/ Pertinent Information:

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