Assign A Case

Please fill out the form below as thoroughly as possible and click submit to send your request. An ACCUSOURCE INVESTIGATIVE SOLUTIONS, INC. representative will contact you to confirm the assignment upon receipt.

Your Information				Requested Service
Name:				Type of Service:	1 Day Surveillance
Company:					2 Day Surveillance
Email:					3 Day Surveillance
Phone:					Background Investigation
Fax:					Activity Check
Address:					Other
City:				Is case in Litigation?	Yes No
State:				Any Prior Surveillance?	Yes No
Zip:				Is claimant known to be suspicious?	Yes No
Comments:				Comments/Instructions:
Subject Information
First Name:				Internal Case #:
Middle Name:				Date of Incident:
Last Name:				Injury or Loss:
SSN:				Represented:	Yes No
Gender:	Male Female			Type of Claim:	-- Please Select -- WCLIABSTD/LTDOTH
DOB:	Month Day Year			Insured:
Height:	Feet     inches			Contact Person:
Weight:	lbs			Phone:
Hair Color/Length:				Association:
Race:				Therapy:	Yes No
Marital Status:	Single Married Divorced			Therapy Provider:
Email:				Meeting Dates:
Phone:				Therapy Phone:
Address:				Therapy Address:
City:				City:
State:				State:
Zip:				Zip:
Comments:				Therapy Info:
				Security Code

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