Make An Assignment Please fill out the information below and we will contact you as soon as possible. You may also email or call us for more information. Step 1 of 7 14% Customer InfoName(Required) Company Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Fax Reporting ProceduresMerge Investigations is a paperless environment. Evidence (Reports, Video and Invoice) will be delivered through our secure case management system.If you would prefer or require hard copies of any evidence please check the appropriate box below: Report Video Invoice Should we Carbon Copy (CC) anyone on any Evidence?Share this Info Report Video Invoice Recipient Info Loss/Accident/Incident InformationClaim Number(Required) Alleged Injuries(Required) Date of Loss(Required) MM slash DD slash YYYY Type of Loss(Required)Workers CompLiabilityFMLAAttorneyAutoPersonal Injury (PIP)IndividualSelf InsurerHRDomesticRestrictions Employer/Insured(Required) Employer/Insured Point of Contact Employer/Insured P.O.C. Phone Employer/Insured P.O.C. Email Defense Counsel Point of Contact Defense Counsel P.O.C. Phone Defense Counsel P.O.C. Email Third Party Administrator Insurance Carrier Loss Description Subject/Claimant InfoFirst Name(Required) Middle Name Last Name(Required) Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code SSN(Required) DOB(Required) Phone(Required) Gender(Required)please selectMaleFemaleUnknownEmail Height Weight Race Marital Statusplease selectMarriedSingleDivorcedCurrently Working?please selectNoYesHair Color Hobbies Comments Build Your Service RequestService Request Surveillance Background Facility Canvass S.C.A.N.® (Deep Web Investigation) Alive & Well/Direct Contact Investigation Activity Check Field Investigations (AOE/COE, Scene Investigation, Subrogation Investigation, Record Retrieval) SIU (Special Investigation Unit – Fraud Investigations) Voir Dire Advantage (Jury Panel Analysis) Video Duplications Surveillance RequestAuthorized Days012345678910Rush? Yes Complete Date MM slash DD slash YYYY Comments/InstructionsBackground RequestBackground Request Full Comprehensive Background Check Criminal Check Civil Check Registered Vehicle Check Record Search (Police Report, Certified Records, EMS Report, Other) Business Search Auto Accident Check Driver’s History Check Motor Vehicle Tag Search Locate/Skiptrace SS Number Verification Asset Check Other Comments/InstructionsFacility CanvassHospitalsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)PharmaciesNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Urgent Care ClinicsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Diagnostic/ImagingNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)OrthopedicsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)ChiropractorsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Primary CareNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Gym/Health ClubNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Physical TherapyNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Golf CourseNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Athletic LeaguesNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Educational InstitutionsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)OtherNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Details (if other) Do you have a medical release? Yes No If yes, please attach the same.Known Treatment Facilities Should known facilities be omitted from our search? Yes No Comments S.C.A.N.® (Deep Web Investigation)Known Subject Associates Known Subject Alias Known Subject Username(s) Subject Email Address(es) Specific Activities of Interest Comments/InstructionsAlive & Well/Direct Contact InvestigationWidow, Claimant or Dependent?WidowClaimantDependentComments/InstructionsActivity CheckComments/InstructionsField InvestigationsLoss Location Point of Contact Name Point of Contact Phone Point of Contact Title Field Investigations Full AOE/COE – Compensability Investigation Full Subrogation Investigation Recorded Statements Non-Recorded Interviews Written/Signed Statements Scene Photos Scene Measurements First Responder Reports Records Check (Police Report, Cert. Records, etc.) Neighborhood Canvass/Witness Identification Property Damage Appraisal Documentation (Personnel Files, Maintenance Records, Security Video) Other Recorded Statements From Non-Recorded Interviews From Written/Signed Statements From Other SIU Investigation/Fraud Investigation/SIU ReferralDate of suspected questionable activity MM slash DD slash YYYY Loss Location Names of involved agencies to date Type of Fraud SuspectedPlease selectWorkers CompLiabilityInternalCheckAutoProperty CasualPremiumApplicationDescription of suspicions or alleged fraud Description of documentation/evidence to support suspicions or alleged fraud Name of Witness(es)/Informant(s)/Person(s) with information of alleged fraud Voir Dire Advantage (Jury Panel Analysis)Anticipated Trial Date (if known) MM slash DD slash YYYY Trial Location When are you available for a pre-trial discussion? MM slash DD slash YYYY Discussion can take place telephonically, via web conference, or in-person, depending on location.Preferred Contact MethodPhoneWeb ConferenceIn-PersonTo Be DeterminedPotential Algorithm Search ParametersPolitical AffiliationReligious ViewsLevel of EducationRelationship StatusOther/To Be DeterminedAre you interested in having a Merge representative attend trial?YesNoTo Be DeterminedVideo DuplicationsWhat case? Dates? # copies? Recipient Name All or Date SpecificAllDate SpecificDVD or Digital Link?LinkDVDBoth DVD and LinkDate Due Recipient Address DocumentsIf you have any other documents that would assist us in our investigation, please attach. Drop files here or Select files Max. file size: 8 MB. Other CommentsComments