Insurance Order Form | Tinsley Investigative Services, Inc.

INSURANCE CLAIM INVESTIGATIVE REQUEST

ALL FILES ARE KEPT 100% CONFIDENTIAL

All information including this request is kept confidential. Fields marked with an asterisk (*) are required. If you need to speak with us personally, simply call us at 801.225.6100. A case manager will be pleased to answer any questions you might have.

Insurance Claim Investigative Request Form

Company Name

Your Name *

Your Position *

Your Phone Number *

Your Email Address *

Claim Number *

Claimant's Full Name *

Claimant's Confirmed Address

Nature of Claim or Injury *

Date of Loss *

IME? *

Yes

Scheduled

Unknown

FCE? *

Yes

Scheduled

Unknown

Claimant Restrictions

Budget for this case *

Due Date for this case *

Primary Case Objectives *

Special notes about this claim

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