Submit a Claim
Client Name
Client Phone:
Address:
City / Town:
Zip Code:
State:
Company Name:
Fax #:
Email Address:
Claim #
Surveillance Professionals Investigations, L.L.C.
Phone: (717) 422-5627/ (570) 639-5202 | Fax: (717) 422-5627 / (570) 639-5202
Weight
Height
Race
Contact Phone #
Contact at Employer
Claim #
Injury or Loss
Date of Accident / Illness
State
City
Address
Claimant Last Name
Claimant First Name
Represented
Hair Color
Is case in litigation
Is claimant known to be suspcious
Claimant Phone #
Marital Status
Social Security #
Date Of Birth
Zipcode
Any Previous Surviellence
1 Day Surveillence
Any known physical therapy, appointments, hearings, etc.
Additional information or comments you may have:
3 Day Surveillence
2 Day Surveillence
Activity Check
Wellness Check
Background Investigation
Employer
Would you like us to call you?
Would you like us to e-mail you?
Vehicle Color
Vehicle Make
Vehicle Model
