P.O. Box 22
Nashville, IL 62263
Phone: 618-327-9526
Toll free: 800-995-7717
Fax: 618-327-9070
AIS@midwestinvestigators.com

Contact Us

Assignment Request

Claim #

SIU #

* Name

* Company

* Address

* City, State & Zip

* Phone

Fax

* Email

Primary Contact:

Update/briefing method:

* Type of Assignment (check all that apply)

Surveillance
Activity Check
Claim Investigation
Database Research
Widow Check
In Person
Recorded Statement
Background Check
Alive and Well Check
Court Record Check
Pre-Employment Background Check
Subrogation
Intellectual Property
Work Comp Surveillance
Domestic
Security Matter
Undercover Operations
Process Service
Executive Protection
Security Camera Installs
Other

If other, please explain

Secure Documents (check all that apply)

Criminal
Civil
Marriage License
DBA
Asset
Police Report
DMV/DOT

Budget / Due Date

* Budget Days or Budget Hours:

* Budget Maximum $

Schedule Instructions:

Due Date:

Insured / Additional Information

Insured

Contact

Acceptable to Contact Insured

Yes
No

Type of Loss

Has file been previously investigated

Is the report available

Yes
No

Additional Information or Instructions

Subject Information

* Full Name

* Other Names Used

* Subject Address:

* Subject City, State & Zip

* Subject Phone

Social Security #

Drivers License #

Occupation

DOB

Date of Injury

Type of Injury

Restrictions

Physical Description

Sex

Hair

Eyes

Height

Weight

Race

Glasses

Additonal Description

Marital Status

Spouses Name

Children/Sex/Age

Family Details

Hobbies

Other Information

Vehicle Info

Attorney's Name

Attorney's Phone

Attorney Full Address

Treating Doctor / Rehab Facility Information

Treating Doctor / Rehab Facility

Facility Address

Facility City, State, Zip

Facility Phone Number

Additional Information

Known Appointments


* Please enter the security code shown below:

Captcha Image

      


Illinois Agency License: 117-000899
Indiana Agency License PD10600004
Kentucky Agency License KYPI-0123
Missouri Agency License-Not Required
Illinois Security Agency License: 122-001103

24 HOUR SERVICE