New Assignment Form

Assignment Request Form * required field(s)
Claim #: Date of Referral:   10-29-2020

Last Name: *
First Name: *
Company: *
Address: *
Address (cont): 
City: *  
State: *
Zip Code: *  
Phone Number: *
Alt Phone Number: 
Fax Number: 
E-Mail Address: *

Additional/Alternate Contact  Primary Contact:  Update/briefing method: 

Type of Assignment (check all that apply)*
Canvass    Rush

Canvass Selection/Locations: 
Radius/Locations
Radius:  Miles
Limited Canvass (15 Locations)
Basic Canvass (25 Locations)
Premium Canvass (35 Locations)
Platinum Canvass (50 Locations)
 
Additional Locations: 
Additional Services
Social Networking Profile
Comprehensive Database
Basic Database
Skip Trace
Location Choices
Hospitals
Urgent Care Clinics
Doctor's Offices
MRI Facilities
Pharmacies
Chiropractors
Gyms / Health Clubs
Rental Facilities
Kennels / Pet Boarding
Medical Centers
Orthopedic Specialists
Physical Therapists
Pain Management
Other (specify in instructions)
 

Insured / Additional Information
Insured:
Contact:
Phone:
Contact Insured: 
Has file been previously canvassed:
Is the report available:
Type of Loss: 
 Signed Medical Release:  

Subject Information *
Last Name:  First Name:  Middle Name: 
Alias(s): 
Address: 
Address (cont): 
City:   
State:  Zip Code: 
Phone Number: 
Alt/Mobile Number: 
Social Security #: 
Occupation: 
 
DOB: 
 Month Day Year
 
Date of Injury: 
 Month Day Year
Type of Injury: 
Restrictions: 

Canvass Search Areas
  Search Area #1 Use Subject's Address
Address: 
Address (cont): 
City:   
State:  Zip Code:   
Search Area #2
Address: 
Address (cont): 
City:   
State:  Zip Code:   
Search Area #3
Address: 
Address (cont): 
City:   
State:  Zip Code:   
Search Area #4
Address: 
Address (cont): 
City:   
State:  Zip Code: 
Search Area #5
Address: 
Address (cont): 
City:   
State:  Zip Code: 
Search Area #6
Address: 
Address (cont): 
City:   
State:  Zip Code: 
Search Area #7
Address: 
Address (cont): 
City:   
State:  Zip Code: 
Search Area #8
Address: 
Address (cont): 
City:   
State:  Zip Code:   

Search Exclusions
Exclude this Facility/Area: 
Exclude this Facility/Area: 
Exclude this Facility/Area: 
Exclude this Facility/Area: 
Exclude this Facility/Area: 
Exclude this Facility/Area: 
Exclude this Facility/Area: 

Treating Doctor / Rehab Facility Information
Treating Doctor / Rehab Facility: 
Address: 
Address (cont): 
City:   
State:  Zip Code:   
Phone Number: 
Known Appointments: 
Misc Info: 

Attach Database/Picture/Info to Assignment: 
Attach Database/Picture/Info to Assignment: 
Attach Database/Picture/Info to Assignment: 

Additional Information or Instructions:
Coupon / Promo Code: 
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