NJC Investigations

Assignment Sheet for N J C Investigations, Inc.
N J C Investigations, Inc.
Send hard copy to correct state’s address

	Phone:	(800) 261-1215
	FAX- NY:	(800) 261-1215
	FAX- Fl:	(786) 208-5802
	Email:	info@njcinvestigations.com

To: N J C Investigations, Inc.

From:

Name:
Title:
Company:
Address:
Phone:
File No.:



Services Needed
	Surveillance
	Medical Malpractice
	Background Investigation
	Asset Check
	Witness Locate
	Product Liability
	General Liability
	Personal Injury
	Insurance Investigation

Insurance Company File # and address info?

Needs/Comments?

Plaintiff’s Data

Birth date?

Sex?

Race?

Full Name?

SSN#?

Current Street address:

City, State, Zip:

Claimant Subject Data

Height?
Weight?
Hair Color?
Hair Style?
Build?
Glasses?
Moustache?
Beard?
Married?
Name of Spouse?
Dependants?
Hobbies?
Type of Vehicle Driven?

Employer Information:

Claimant's Job Description/Title?

Describe Injury/claim?

Is claimant working?

Last Date Worked?

Tips you received regarding other employment or activities?

Date, Time and Address of next Dr. Appointment?

Signed: