Private Investigator and Surveillance Service, Shannon Investigations Inc.

Surveillance Order Form
Agency License #: A-98-00005

Form Type:

Claim Rep:

Claim #:

Insured:

Return To (if surveillance needs to be sent to defense counsel enter attorney name here):

Claimant Name:

Address:

City:

State:

Zip:

Phone:

Race:

Sex:

Height:

Weight:

Check all that apply:

BeardMustacheGlasses

Hair Length and Color:

Further Descriptive Details:

Date of birth:

Social Security Number:

(Please list all Identifying information: DOB/SSN/DL #, as this information may become vital if the surveillance assignment turns into a locate investigation)

Spouses Name:

Spouses Date of birth:

Children:

Alleged Injury:

Physical Restrictions:

Date of Loss:

Type of Claim:

Claimants Vehicles:

Claimants Occupation:

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Claimants Employer Name:

Claimants Doctor (Name & Address):

Next Scheduled Appointment:

Claimants Attorney (Name & Address):

Client's Comments To Investigator:

Number of Days:

Weekdays/Weekends:

(Note: If requesting weekend days we recommend that you already have specific knowledge that your claimant/subject is active or involved in specific activities on the weekend (because weekend activity varies from person to person); otherwise we recommend that you enter UYJ=Use Your Judgment as our investigators will do a weekend day if the claimant/subject’s weekday pattern does not yield video results because of the claimant/subject’s indoor occupation and or circumstances etc. Further, requesting weekend days only may lengthen the standard turn around of the assignment simply because of the physical fact that there are only 2 weekend days in each week.)

Consecutive Days:

YesNo

(Note: Consecutive day requests involving weekend days may lengthen the turn around of your assignment due to physical scheduling availability of a Fri./Sat./Sun and or Sat./Sun./Mon.)

Rush Assignment:

YesNo

There is an additional $100 rush charge for all assignments that must be returned within 1 week.

Additional DVD Copy $20:

YesNo

(All surveillance assignments include 1 copy of the DVD already, if you have indicated your surveillance be returned to your defense counsel, indicate here if you need a second copy sent to yourself and or the adjuster).

Your Contact Information

First Name:

Last Name:

Company Name:

Address Line1:

Address Line2:

City:

State:

Zip Code:

Country:

Preferred Phone #:

Secondary Phone #:

Email Address:

Defense Counsel and or Adjuster Contact Information

First Name:

Last Name:

Company Name:

Address Line1:

Address Line2:

City:

State:

Zip Code:

Country:

Preferred Phone #:

Secondary Phone #:

Email Address:

Shannon Investigations, Inc.
P.O. Box 15945
Plantation, FL 33318

Phone: (954) 797-9410
Fax: (954) 797-9418
Email: Click Here