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Investigation Request Form

  • Note:This investigation request form is intended for the use of existing Veritech clients. If you have never used the services of Veritech before, then you must talk to a Veritech representative before your case will be handled.

If you have any questions , please contact Veritech via telephone (770-517-8879) or email us at info@veritechinvestigation.com

Client:                      *Name:

*Requester:

*Email: 

*Address:

*Phone:

Fax:

   

Date of Loss:

Case Types:
(Select all that apply)

Workers' Comp     Other

What raises your suspicions
about this case?

Activity Desired:
(Select all that apply)

Surveillance    Activity Check     
Other

Case Information

 

Today's Date:

       Date needed by:

Budget:

Insured:

Physician:
Firm:


Phone:
Date of next Appointment:


Address:

Medical Supplier:

Medical Phone:

Address:

Subject Information  

Subject/Claimant:
Alias:


Address:

Phone:    DOB:   S.S.N.:

Represented by Attorney:

Race:

Sex:

Height:

 Weight: Facial Hair:

Build:

Glasses:

Hair Color:

Hair Style:
Married       Divorced Single Separated

# of Dependents:

Other Features:

Subject's Car:

 Make:   
Model:
  Year:   Color:  
 Tag # and State:

How often would you like a report on this case?

Special Instructions:

Please only hit submit once, then choose your destination

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