Paragon Services - Surveillance Request Form

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Online Secure Surveillance Request Form

Please enter the information and click "Submit" to send your request. Your information will be securely transmitted and you will be contacted when the request is received.

If you have any questions about how to fill out the form, please call us at Tel: (888) 467-1823 for assistance.

* Denotes Required Field

Contact Information

*Requester:
*Company:
*Address:

*City:
*State:
*Zip:
*Phone:
Email:
Toll Free:
FAX:

How did you hear about AIS?:
*Type of Claim?:
*Date of Loss:
*Insured:
*Claim Number:
*Has this case been worked before ?:
*If so by Whom? AIS/Other:

Claimant/Subject Information

*Subjects Full Name:

*Address:

*City:

*State:

*Zip:

Phone:

DOB:

SSN:

Race:

Hair Color:

Height:

Weight:

Sex:

Marital Status:

Spouse's Name:

Driver's License #:

Special Physical Characteristics
(i.e. glasses, beard, tattoos, scars, jewelry):

Occupation:

Hobbies:

Alleged Injury:

Restrictions:

Children/Ages:

Vehicle 1(Make/Model): Tag Number:

Vehicle 2(Make/Model): Tag Number:

Employer/Rehab/Physical/Attorney Information

Subject's Employer:

Employer Contact:

Employer Address:

City: State: Zip:

Employer Phone:

Rehab Company:

Rehab Contact:

Rehab Address:

City: State: Zip:

Rehab Phone:

Physician:

Physician Address:

City: State: Zip:

Physician Phone:

Subject's Attorney:

Attorney's Address:

City: State: Zip:

Wage Loss Paid: Weekly Amt:

Exposure:
Address Sent:

City: State: Zip:

Any known appts.,
hearings, etc.:

Specific Instructions/Objectives

Why are you assigning surveillance?:

Client Objective 1:

Client Objective 2:

Client Objective 3:

Authorization (Select at least one)

*Budget (Days/Amt):

Standard Surveillance 8 hrs/per day

Background Check (civil/criminal/asset)

Activity Check (3-4 hrs surveillance and neighborhood inquiry if warranted)

Other

Packaging (Choose all that apply)

*Report: Email     Hard Copy

*Photo Snippets: Email     Hard Copy

*Invoice: Email     Hard Copy

*Video: VHS CD-ROM 8mm

Other:

Due Date

*Due Date

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