New Assignment Form

Please complete the form and press the Submit Assignment button when complete. Press the button only ONCE for each assignment.

Note: Pressing the "Enter" key will submit the form. Use the mouse or the "Tab" key to move forward and "Shift-Tab" to move backward. If you choose, you can come back to the form change information and then submit a new assignment. You can clear the form at any time by pressing the Refresh button in your browser.

Case Request Information Client Information
Company Contact Phone 1 Phone 2		Address 1 Address 2 City,State,Zip
Fax
Toll Free		E-mail
Request Date Claim Type Date of Loss Insured		Claim File# SIU File #
Claimant Information
Claimant Phone (H) Phone (W)		Address 1 Address 2 City,State,Zip
SSN		Marital Status
DOB		Sex
Race		Hair
Height		Weight
Physical Description
Reported Injury
Restrictions
Employer
Occupation
Weekly Comp Rate
Claimant Attorney
Miscellaneous
Case Budget:	Amount $ or Days or Hours
Video Format: VHS Tape Video CD Video E-Mail
Case Objectives:

Special Client Instructions:

Case Comments:

We will confirm by phone and e-mail that we have received your request. Thank you for using East Coast Investigative Services.

New Assignment Form

Last modified: November 20, 2003 site design by HarborIT.net