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)CompanyAddress(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? Add New Recipient 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 InsurerHRDomesticRestrictionsEmployer/InsuredEmployer/Insured Point of ContactEmployer/Insured P.O.C. PhoneEmployer/Insured P.O.C. EmailDefense Counsel Point of ContactDefense Counsel P.O.C. PhoneDefense Counsel P.O.C. EmailThird Party AdministratorInsurance Carrier Subject/Claimant InfoFirst Name(Required)Middle NameLast 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 selectMaleFemaleUnknownEmailHeightWeightRaceMarital Statusplease selectMarriedSingleDivorcedCurrently Working?please selectNoYesHair ColorHobbiesComments 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) S.I.U. (Special Investigation Unit – Fraud Investigations) Voir Dire Advantage (Jury Panel Analysis) Video Duplications 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