Merge Investigations, Inc.

Service Request


Customer Info


Name*

Address

City

State

Zip

Company

Phone*

FAX

Email*


Subject/Claimant Info


Claim # *

Subject Name *

Phone *

DOB *

Represented *
yesno

Date of Loss *

Injury *

Restrictions

Job Duties

Subject Currently Working?

Address *

City *

State *

Zip *

SSN *

Employer/Insured *

Employer Contact

Employer Phone

Employer E-mail

Height

Weight

Race

Hair Color

Sex

Comments


Investigative Request


Surveillance

Authorized Days

Rush?

Complete Date

Comments/Instructions


Background Investigation

Full Comprehensive Background Check

Criminal Check

Civil Check

Registered Vehicle Check

Record Search (Police Report, Certified Records, EMS Report, Other)

Business Search

Comments/Instructions

Auto Accident Check

Driver's History Check

Motor Vehicle Tag Search

Locate/Skiptrace

SS Number Verification

Asset Check

Other


Investigative Canvasses

Hospital Canvass

Pharmacy Canvass

Physician Canvass

Clinic Canvass

Imaging Facilities Canvass

Comments/Instructions

Gym and Health Club Canvass

Golf Course and Club Canvass

Chiropractors Canvass

Other


SCAN (Deep Web Investigation)

Comments/Instructions


Alive and Well Check

Comments/Instructions


Acitivity Check

Comments/Instructions


Special Investigations

Special Investigations Unit (SIU) Services

Claimant and Witness Statements

Witness Location

Translations

Workers Compensation/Compensability Investigation

Accident Scene Investigation

AOE/COE

Video Inspections

Other


Reporting and Procedures


Report

E-mail

Hard Copy Mailed

Invoice

E-mail

Hard Copy Mailed

Video

DVD

Data CD

Status Update

Verbal Update

E-mail Update

No Update

Comments/Instructions


C.C. Parties

Report

Video

Information

Report

Video

Information

Report

Video

Information

Report

Video

Information


* Denotes required field

Exceeding Expectations for over 18 Years