SERVICE REQUEST FORM - PRIVILEGED AND CONFIDENTIAL

Please be assured our e-mail is secure and confidential as set forth by the guidelines of our company. Each request that is received is reviewed by our management team before initiating the assignment. We at Larrek Investigation have the right to use our discretion on all assignments.

If you do not wish to send your request by e-mail, please feel free to print the form and send it to us by facsimile at 1-519-576-4659, or you may speak to an individual at 1-888-576-3010. *A retainer fee may be required for certain requests. If you have any problems with this form, please e-mail info@larrekinvestigation.com.

Fields in red must be completed.

TYPE OF INVESTIGATION

Type of Request:
Select all that apply

Insurance

Corporate

Locate

Subrogation

Surveillance

Background

Activities

Other *

If Other, specify: 

Specific Instructions for Investigation:

Reporting Instructions:

CONTACT INFORMATION
Company: Client Name:
Address: City:
Phone Number:

Fax:

Email:

Claim/Policy #:

Insured:

$ Limit:

CLAIMANT/THIRD PARTY INFORMATION
Claimant Name:

Date of Birth:

    

Current Address:

Previous Address:

Phone Number:

Gender:

Male    Female

   Marital Status:    Single    Married    Separated/Divorced    Widowed

Height:

Weight:

          Description:

   Scheduled Appointments:

VEHICLE INFORMATION

Driver's Licence #:

License Plate:

Registered To:

Year/Make/Model:

Additional Vehicles: 

EMPLOYMENT INFORMATION

Employer:

Employer Address:

Employer Phone #:

Occupation/Job:

Additional Comments: 

CLAIM INFORMATION

Date of Loss:

  (DD/MM/YYYY)

Claimants Reported
Injuries or Restrictions:

Previous Surveillance
or Claims:

 

Toll Free 1-888-576-3010 info@larrek.com