Requesting Company Requestor Name Requestor Address Requestor Telephone Requestor Email File Number Type of Investigation Surveillance IME Only IME + Surveillance Background Activity Check Locate Obtain Statements Other See Additional Notes How Much Investigation   Hours Dollars Days Other (see notes) Claimant's Last Name Claimant's First Name Address Social Security Number Date of Birth Telephone Number Date of Loss Injury Type Insured Claimant Represented  Yes No Pending Medical Exams None Yes No Date/Time of Exam Location of Exam Doctor or Exam Company Scheduled Hearings Type IAB Conference Conciliation Other None Hearing Date/Time/Location Additional Notes Confirm Order By   Fax Email Telephone None Required