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Surveillance      Investigation

Claim #

Client
Adjuster/Examiner
Claim Centre
Telephone
Email - required field
Date of Loss
Comments
Claimant
Surname
Given Names
Address
City
Province/State
Postal/Zip Code
Telphone
Cellular
Identifiers
DOB
DL Number
Province/State
Description
Photo Yes     No
Height
Features

Race
Weight
Sex Male     Female
Hair
Age
Employment
Occupation
Employer
Address
Telephone
Vehicle #1
Make
Model
Year
Plate Number
Province/State
Colour
R/O Claimant     Other
Vehicle #2
Make
Model
Year
Plate Number
Province/State
Colour
R/O Claimant     Other
Medical
Injuries

Physician
Address
Telephone

Physio
Address
Telephone

IME Date
IME Dr.
Address
Telephone

Defence Counsel
Lawyer
Firm
Address
Telephone

E/D
Date
Location

Trial
Date
Location

Hours Approved
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