F O R E N S I C accountants inc.

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First Name:

Last Name:

Company Name:

Email Address:

Phone (optional)

Question or Comment:

Request for Investigation Form

INSURANCE COMPANY INFORMATION:

Company:

.Date:

Address:

Zip:

Requested by:

Telephone:

Fax:

CLAIM NO.

Assured:

Address:

Zip:

Accident Date:

Type of Injury:

SUBJECT:

Name:

DOB:

Address:

Occupation:

Telephone:

Social Security #:

Name & Address of Subject's Attorney:

Telephone:

TYPE OF INVESTIGATION:

Financial

Loss of Earnings

Property Loss

Business Interruptions

Burglary Loss

Special (describe in "Remarks" below)

Fidelity Loss

For No-Fault Claims: Maximum lost wage benefits allowed under claimant's policy $

REMARKS: (Provide all relevant information and instructions.)