Merge Investigations, Inc.

Service Request

* Denotes a required field


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 *

Date of Loss *

Type of Loss

Restrictions

Employer/Insured

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


Subject/Claimant Info


First Name *

Middle Name

Last Name *

Address *

City/State/Zip *

SSN *

DOB *

Phone *

Gender

Email

Job Duties

Represented
Yes No

Height

Weight

Race

Marital Status

Currently Working?

Hair Color

Hobbies

Comments


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)

Voir Dire Advantage (Jury Panel Analysis)

Video Duplications


Documents


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


Other Comments


Comments


* Denotes a required field

Exceeding Expectations for over 25 Years