Beckford Investigation & Consultant Bureau

Assignment Form: Please complete as much of this form as you can, remembering that the more information that you provide will assist us in handling your case more efficiently.

Clients First Name
Clients Last Name
Clients Company Name
Address Line 1
Address Line 2
City
State
Zip Code
Country
Clients Daytime Phone	() -
Evening Phone	() -
Fax	() -
E-mail Address
Case Type- Activity Check
AOC/COE- Statements
Investigation
Subrosa - Surveillance
How many hours are being assigned for your surveillance or activity check
Process Service
Research / Missing Person
Today's Date
Due Date
Your Claim Number
Date of Injury
Type of Injury
Claimant's Name
Claimant's Address
Claimants City
Claimants State
Claimants Zip
Claimants Home Phone	() -
Additional Phone #1	() -
Additional Phone #2	() -
Date of Birth
Social Security Number
Height
Weight
Color of Eyes
Occupation
Employer
Employers Address
Employers City
Employers State
Employers Zip
Employers Contact Name
Employer's Contact Phone Number	() -
Obtain Statements from Claimant
Statements from / Witnesses
Employer / Supervisor
Is Claimant Represented?
His Attorneys Name
Obtain Medical Releases & Personnel Records?
Comments or Additional Notes

Thank you for this assignment you will be receiving a comfirmation E-mail which will be sent upon review.

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BECKFORD INVESTIGATION & CONSULTANT BUREAU.

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