Order Claims Investigation

* = Mandatory Fields Type of Investigation *

Activity Checks

Work, Sports & Leisure Search - $449 www Search - $149 Alive & Well Check - $149

Medical Checks

Hospital Check - $199 Chiro Check - $199 MRI Check - $199

Financial

Assets Search - $299

Investigations

Contingency Locate - $119-299 Employment Search - $249 Statements Hourly Vehicle Photos Hourly Scar Photos Hourly Locus Photos Hourly Household Member Search - $199

Record Searches

Criminal & Civil Record Search (per county) - $199 Workers' Comp Claims History - $149

Group Packages

Work & Leisure Search + Hospital History Search/Medical Check - $598 (SAVE $50!) www Search + Field Check & Form Delivery Check - $198 (SAVE $20!) Two or more Medical Checks - $189 (per check - SAVE $10 each!)

Other Claim Service Requested

Adjuster Information
First Name *
Last Name *
Company *
Address *
City *
State *	Zip *
Phone *
Fax *
Email *
Claim Information
Claim No. *
Date of Loss
Type of Claim	Liability WC Property Auto Other
Other
Claimant Information
First Name *
Last Name *
Gender	Male Female
SSN
Date of Birth	(MM/DD/YYYY)
Address *
City *
State *	Zip
Home Phone
Marital Status	Married Single Divorced
Companion/Spouse Name
Claimant Occupation
Name of the insured
Address
City
State	Zip
Can Capital Investigating contact insured if needed?	Yes No
Insured Contact
Phone
Alleged Injuries
Prior Medical Problems
Hospitals/Doctors Visited
Is the claimant/subject legally represented?	Yes No Unknown
Case in Suit	Yes No
Vehicle Information
Year	Color
Vehicle Make
Vehicle Model
License Plate Number	State
Other Vehicle
Year	Color
Vehicle Make
Vehicle Model
License Plate Number	State
Remarks
Set Your Preferences
Receive E-mail copies of submitted assignments?	Yes No