Merge Investigations, Inc.

Service Request

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Customer Info


Name*

Address

City

State

Zip

Company

Phone*

FAX

Email*


Reporting Procedures


Merge 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 Information


Claim Number*

Alleged Injuries *

Employer/Insured First Name

Employer/Insured Last Name

Employer/Insured Email

Restrictions

Insurance Carrier

Date of Loss *

Type of Loss

Defense Counsel First Name

Defense Counsel Last Name

Defense Counsel Email

Third Party Administrator


Subject/Claimant Info


First Name *

Middle Name

Last Name *

Address *

SSN *

Email

Height

Weight

Gender

Comments

Job Duties

Represented
Yes No

Phone *

City/State/Zip *

DOB *

Marital Status

Currently Working?

Race

Hair Color

Hobbies


Build Your Service 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)

Video Duplications


Documents


If you have any other documents that would assist us in our investigation, please attach.


Other Comments


Comments


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Exceeding Expectations for over 25 Years