To be completed at the request of Calderbank Investigations after initial contact has been made.

Case Information
Investigation Type:
Other:
Completion Deadline: Day:  Month: Year:
Trial or Hearing Date: Day:  Month: Year:
Previous Surveillance Performed? Yes:   No:
(If yes, please fax over previous report if available)
Alleged Injury:
Physical Restrictions:
File/Claim Number
Date of Loss:  Month: Year:
Insured/Employer:
Occupation of Claimant / Subject:
Subject / Claimant Represented? Yes     No
What is the purpose of this investigation?
Client Information
Are you a first time client? Yes
No
Company:
Requestor:
Address:
Address2:
City:
State:
    Zip:
Phone:
Fax:
Email Address:
Secondary Client Information (if applicable)
Client:
Phone:
Fax:
Email:
Subject Details 
Name:
Address:
Address2:
City:
State:
    Zip:
Telephone:
Date of Birth:
SSN:
Drivers Lic. # (if available):
Subject Identifying Information
Sex:
Race:
Hair:
Build:
Height: ft.    in.
Weight: lbs.
Other Descriptive Details (tattoos, disabilities, scars, etc.):
Marital Status:
Spouse Name:
Vehicle Information
Vehicle #1  
Make:
Model:
Color:
Tag# Year:
Vehicle #2  
Make:
Model:
Color:
Tag# Year:
Further Details
Does the subject have a history of violent behavior? Yes (If yes, two crews are required)
No
Restrictions:
 Day Limit: Dollar Limit:  
Are there specific days for the surveillance to be conducted on? Yes   No
(If yes, please detail)
If 2 crews are required (ie: rural areas), do we have permission to proceed? Yes
No
Special Instructions:
Referred By:


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Serving Northern New England

State of Maine Licensed

State of New Hampshire Licensed

Calderbank Investigations
PO Box 10928
Portland, Maine 04104

Tel: (207) 773-8715
or (888) 374-7356
Fax: (888) 374-7357
Email Us

 

 

 

 


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