Insured Information
Insured's Name:
Insured's Address:

,
Insured's Telephone Number:
Investigative Request
Assignment Type:
Surveillance for Days
Activity Check
Accident Scene Investigations
IME
FCE
Deposition
Locate
Database Services:
Criminal
Civil
Federal
Comprehensive
Drivers License
  Other:
Budget:
Special Instructions, Description/Location of Accident:
Property Appraisal
Type of Coverages:
Limits:
Deductible:
Cause of Loss:
Date of Incident:
Emergency Services Performed:
By
Recorded Statement
Claimant Statement:
Written   Recorded   Interview Only
Insured Statement:
Written   Recorded   Interview Only
Witness Statement:
Written   Recorded   Interview Only
Other:
 
Medical Records/Wage Authorization
Hospital Scan
Computer Background Search
      Include Criminal History
Subrogation
Attend Mediation/Hearing
 
Records Request
Police Report Dept Name: Report Number:
Fire Report Dept Name: Report Number:
Medical Records Retrieval
Medical Release
Employment Records
Other:
Special Instructions and Additional Information:

Assignment
(* Denotes Required Fields)
     Rush     New          Re-Assignment
CCS Number:
Client Information
*Name:
*Company:
*Address:
,
*Telephone Number: Fax Number:
*Email Address:
Confirmations: Email Fax
Updates: Email Verbal
Reports: Email Mail
Video: CD VHS
CC
Report    Video    Invoice
Name:
Company:
Address:
,
Telephone Number: Fax Number:
Email Address:
Claimant Information
Name:
Address:

,
Telephone Number:
SSNumber: DOB: (mm/dd/year)
Height: Weight: Sex:
Race: Hair: Eyes:
Other Characteristics:
Vehicles:
Represented:    Yes           No 
Employment:
Previous Investigation:    Yes           No 
Description of Injury:
Claim Information
Type of Claim:
Workers' Compensation Auto
General Liability Property
Other:
Client File Number:
Date of Loss: (mm/dd/year)
Injury:
Claim Status:
Contact(s):
Scheduled Appointments:
 
Email Us
Complete Claims Services, Inc., P.O. Box 51473, Jacksonville, FL 32240-1473
Phone: (904) 694-1100 / Fax: (904) 694-1108 / Toll-Free: 1-877-647-8667
Florida License # A2000140 - Georgia License # PDC002197
© 2006 Complete Claims Services, Inc.