Order Surveillance
(click here for a fax-ready document)


* = Mandatory Fields

Adjuster Information
First Name *
Last Name *
Company *
Address *
City *
State *   Zip *
Phone *
Fax *
Email *
Claim Information
Budget (days) *
Budget (amount) *
Claim No. *
Date of Loss
Type of Claim Liability
Comp
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
Cell Phone
Email
Claimant Description Yes
No
Height
Weight
Ethnicity
Other
Hair Color
Special Physical Characteristics
(ie. glasses, facial hair, tattoos)
Marital Status Married
Single
Divorced
Companion/Spouse Name
Dependents Yes
No
Unknown
How many?
Child #1 Age   Gender Male   Female   Unknown
Child #2 Age   Gender Male   Female   Unknown
Child #3 Age   Gender Male   Female   Unknown
Claimant Occupation
Out of work
for insured?
Hobbies
Name of the insured
Address
City
State   Zip
Can Capital Investigating contact
insured if needed?		 Yes
No
Insured Contact
Phone
Alleged Injuries
Restrictions
Upcoming Appointments? Yes
No
Type
Other
Appt. Date
Appt. Time
Doctor Name
Address
City
State   Zip
Phone
Is transportation
being provided?		 Yes
No
Conduct surveillance on
date of appt?		 Yes
No
Nurse Case Manager Name
Contact #
TX Physician Yes
No
TX Physician Name
Address
City
State   Zip
Phone
Is the claimant/subject
legally represented?		 Yes
No
Unknown
Subject's attorney name
(if known)
Prior Investigations? Yes
No
Please email prior investigative reports to info@capitalinvestigating.com or
Fax to 877-637-1881
Vehicle Information
Year   Color
Vehicle Make
Vehicle Model
License Plate Number   State
Other Vehicle
Year   Color
Vehicle Make
Vehicle Model
License Plate Number   State
What are you trying
to achieve?
Specific assignment instructions
Remarks
Set Your Preferences
Receive E-mail copies
of submitted assignments?		 Yes
No
Assignment Completion
Please select Standard (15-21 days)
Priority (10-14 days)
RUSH
Due Date (if RUSH selected)