Make An Assignment Please fill out the information below and we will contact you as soon as possible. You may also email or call us for more information. Step 1 of 7 14% Customer InfoName(Required)CompanyAddress(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Fax Reporting ProceduresMerge Investigations is a paperless environment. Evidence (Reports, Video and Invoice) will be delivered through our secure case management system.If you would prefer or require hard copies of any evidence please check the appropriate box below: Report Video Invoice Should we Carbon Copy (CC) anyone on any Evidence?Share this Info Report Video Invoice Recipient Info Loss/Accident/Incident InformationClaim Number(Required)Alleged Injuries(Required)Date of Loss(Required) MM slash DD slash YYYY Type of Loss(Required)Workers CompLiabilityFMLAAttorneyAutoPersonal Injury (PIP)IndividualSelf InsurerHRDomesticRestrictionsEmployer/Insured(Required)Employer/Insured Point of ContactEmployer/Insured P.O.C. PhoneEmployer/Insured P.O.C. EmailDefense Counsel Point of ContactDefense Counsel P.O.C. PhoneDefense Counsel P.O.C. EmailThird Party AdministratorInsurance CarrierLoss Description Subject/Claimant InfoFirst Name(Required)Middle NameLast Name(Required)Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code SSN(Required)DOB(Required)Phone(Required)Gender(Required)please selectMaleFemaleUnknownEmailHeightWeightRaceMarital Statusplease selectMarriedSingleDivorcedCurrently Working?please selectNoYesHair ColorHobbiesComments Build Your Service RequestService Request Surveillance Background Facility Canvass S.C.A.N.® (Deep Web Investigation) Alive & Well/Direct Contact Investigation Activity Check Field Investigations (AOE/COE, Scene Investigation, Subrogation Investigation, Record Retrieval) SIU (Special Investigation Unit – Fraud Investigations) Voir Dire Advantage (Jury Panel Analysis) Video Duplications Surveillance RequestAuthorized Days012345678910Rush? Yes Complete Date MM slash DD slash YYYY Comments/InstructionsBackground RequestBackground Request Full Comprehensive Background Check Criminal Check Civil Check Registered Vehicle Check Record Search (Police Report, Certified Records, EMS Report, Other) Business Search Auto Accident Check Driver’s History Check Motor Vehicle Tag Search Locate/Skiptrace SS Number Verification Asset Check Other Comments/InstructionsFacility CanvassHospitalsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)PharmaciesNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Urgent Care ClinicsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Diagnostic/ImagingNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)OrthopedicsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)ChiropractorsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Primary CareNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Gym/Health ClubNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Physical TherapyNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Golf CourseNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Athletic LeaguesNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Educational InstitutionsNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)OtherNoneCustomary (11 Locations)Expanded (22 Locations)Advanced (33 Locations)Details (if other)Do you have a medical release? Yes No If yes, please attach the same.Known Treatment FacilitiesShould known facilities be omitted from our search? Yes No CommentsS.C.A.N.® (Deep Web Investigation)Known Subject AssociatesKnown Subject AliasKnown Subject Username(s)Subject Email Address(es)Specific Activities of InterestComments/InstructionsAlive & Well/Direct Contact InvestigationWidow, Claimant or Dependent?WidowClaimantDependentComments/InstructionsActivity CheckComments/InstructionsField InvestigationsLoss LocationPoint of Contact NamePoint of Contact PhonePoint of Contact TitleField Investigations Full AOE/COE – Compensability Investigation Full Subrogation Investigation Recorded Statements Non-Recorded Interviews Written/Signed Statements Scene Photos Scene Measurements First Responder Reports Records Check (Police Report, Cert. Records, etc.) Neighborhood Canvass/Witness Identification Property Damage Appraisal Documentation (Personnel Files, Maintenance Records, Security Video) Other Recorded Statements FromNon-Recorded Interviews FromWritten/Signed Statements FromOtherSIU Investigation/Fraud Investigation/SIU ReferralDate of suspected questionable activity MM slash DD slash YYYY Loss LocationNames of involved agencies to dateType of Fraud SuspectedPlease selectWorkers CompLiabilityInternalCheckAutoProperty CasualPremiumApplicationDescription of suspicions or alleged fraudDescription of documentation/evidence to support suspicions or alleged fraudName of Witness(es)/Informant(s)/Person(s) with information of alleged fraudVoir Dire Advantage (Jury Panel Analysis)Anticipated Trial Date (if known) MM slash DD slash YYYY Trial LocationWhen are you available for a pre-trial discussion? MM slash DD slash YYYY Discussion can take place telephonically, via web conference, or in-person, depending on location.Preferred Contact MethodPhoneWeb ConferenceIn-PersonTo Be DeterminedPotential Algorithm Search ParametersPolitical AffiliationReligious ViewsLevel of EducationRelationship StatusOther/To Be DeterminedAre you interested in having a Merge representative attend trial?YesNoTo Be DeterminedVideo DuplicationsWhat case?Dates?# copies?Recipient NameAll or Date SpecificAllDate SpecificDVD or Digital Link?LinkDVDBoth DVD and LinkDate DueRecipient Address DocumentsIf you have any other documents that would assist us in our investigation, please attach. Drop files here or Select files Max. file size: 8 MB. Other CommentsComments