Venture Intelligence Group Inc.

Venture Intelligence Group
P.O. Box 1023
Lawrence, KS 66044

Phone: 866.936.2737

REQUEST FOR SERVICES

Fill in your request below for email submission, or print the form and submit your request by Mail.

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CLAIM/CASE/FILE#:

Rush Request?
Date Received:

Requestor:*

Phone:*

Company Name:

Email:*

Street Address:*

City/State/Zip:*

Claim Type:

Insured:

CLAIMANT/SUBJECT NAME:

Alias:

Social Security #

DOB (month/date/year):

Address:

City/State/Zip:

Phone:

Loss State:

Claimant/Subject
Occupation:

Loss Date:

Marital Status:

Spouse Name:

Dependent Names
& Ages

Sex:

Race: Height: Weight:

Distinguishing Characteristics:

Does Claimant have history of violent behavior?

Description of loss/injury:

Is Claimant currently working?

If yes, list employment info here:

Purpose of investigation:

Claimant physical restrictions:

Description of Claimant vehicles:

Have previous investigations been performed?

Number of days requested:

Are there specific days?

If needed, may we use two surveillance technicians?

SPECIAL INSTRUCTIONS: