Assign A Case

Download PDF Form

This online encrypted form will send your case assignment directly to our home office. We will send you an email confirming the assignment has been received and reviewed by our office before the end of the business day. If you do not receive a confirmation email, please contact us by phone at 954-788-1190, or email us at info@selectiveinvestigations.com.

A PDF download form is also available. Download the form to use as a template. Email or fax the completed form to our office.

Case Assignment Form

Section I: Your Information

Please provide your contact information so our office can confirm and follow up on this assignment.

Your Company(Required)

Your Name(Required)

Your Phone Number(Required)

Country Phone Number

Your E-mail(Required)

Your Address (For New Clients Only)

Street Address City State ZIP Code

Existing clients may leave this blank unless your contact information has changed.

Section II: Claim Information

Enter the claim details, file numbers, requested services, and assignment objectives.

Claim Number(Required)

Insured(Required)

DOL (Date of Loss)(Required)

Type of Claim(Required)

Secondary File Number

Section III: Services Requested

Select all services being requested. Additional service details may appear when certain options are selected.

Services Requested(Required)

Additional Information/Objectives

Please provide any additional instructions, objectives or information that may assist us with this assignment.

Section IV: Subjects

Add each Subject related to this assignment. Select whether the Subject is an Insured, Claimant, Witness, or Other. Additional fields may appear depending on the subject type selected.

Subject 1 Type(Required)

Insured

Claimant

Witness

Other

Subject 1 Name(Required)

Subject 1 Phone

Country Phone Number

Subject 1 Address

Street Address Address Line 2 City State ZIP Code

If the address information is unknown, please enter "Unknown" into the available address fields.

Subject 1 Notes

Please include any helpful information that may assist in our efforts, including the subject’s relationship to the claim, known social media profiles or handles, relevant background details, or any other notes specific to this subject.

Subject 1 Cell Phone

Subject 1 DOB (Date of Birth)(Required)

Subject 1 Physical Description

Subject 1 Vehicle Information

Subject 1 Occupation

Subject 1 Hobbies

Subject 1 Injuries/Restrictions/Work Status

Subject 1 Known Appointments / Medical Appointments / Court Dates

Enter appointment type, date, time, location/address, and any other details

Add Another Subject?(Required)

Yes

Subject 2

Subject 2 Type(Required)

Insured

Claimant

Witness

Other

Subject 2 Name(Required)

Subject 2 Phone

Country Phone Number

Subject 2 Address

Street Address Address Line 2 City State ZIP Code

If the address information is unknown, please enter "Unknown" into the available address fields.

Subject 2 Notes

Subject 2 Cell Phone

Subject 2 DOB (Date of Birth)(Required)

Subject 2 Physical Description

Subject 2 Vehicle Information

Subject 2 Occupation

Subject 2 Hobbies

Subject 2 Injuries/Restrictions/Work Status

Subject 2 Known Appointments / Medical Appointments / Court Dates

Enter appointment type, date, time, location/address, and any other details

Add Another Subject?

Yes

Subject 3

Subject 3 Type(Required)

Insured

Claimant

Witness

Other

Subject 3 Name(Required)

Subject 3 Phone

Country Phone Number

Subject 3 Address

Street Address Address Line 2 City State ZIP Code

If the address information is unknown, please enter "Unknown" into the available address fields.

Subject 3 Notes

Subject 3 Cell Phone

Subject 3 DOB (Date of Birth)(Required)

Subject 3 Physical Description

Subject 3 Vehicle Information

Subject 3 Occupation

Subject 3 Hobbies

Subject 3 Injuries/Restrictions/Work Status

Subject 3 Known Appointments / Medical Appointments / Court Dates

Enter appointment type, date, time, location/address, and any other details

Please include any additional Subject information in the Additional Information / Objectives section.

Section V: Assignment Status, Documents & Delivery

Upload supporting documents and provide final instructions for turnaround time, case updates, report delivery, and invoicing.

Upload All Files

Drop files here or

Accepted file types: jpg, gif, png, pdf, zip, Max. file size: 100 MB, Max. files: 5.

Please upload any files that might assist us or expedite this investigation (Police Report, Accident Report, etc.). Please zip if multiple files.

Turnaround(Required)

Standard (2 weeks)

Less than 2 weeks

Select less than 2 weeks if you need expedited Investigation. You will be prompted for a due date.

Date Needed By:

Assignments requiring same-day or next-day turnaround will be subject to a $100 Rush Service Fee. Obtaining Traffic Crash Reports will not incur any rush fees.

Assignment Updates?(Required)

Yes

We will provide case status updates throughout the investigation. Select no if you prefer to only receive a final report.

Update By

Phone

Both

We will provide case status updates throughout the investigation. Select no if you prefer to only receive a final report.

Report Delivery(Required)

Hard Copy

How would you like the report delivered?

Invoicing(Required)

Hard Copy

How would you like to be invoiced?

Address

Street Address Address Line 2 City State ZIP Code