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UBER Referral Request Form

Please use the following form to submit case details.

Client Information

First Name*

Last Name*

Phone*

Email*

Company*

Payor/Payor Email*

Office Location Street*

Office Location City*

Office Location State*

Office Location Postal Code*

Assigner's Physical City*

Assigner's Physical State*

Carrier*

Claimant Details

First Name*

Middle Name

Last Name*

Street Address

Claimant City

State

Postal Code

Social Security #

Phone

Birth Date

Height

Weight

Hair Color

Sex

Physical Description

Vehicle 1 Make / Model

Vehicle 1 State / Tag #

Vehicle 2 Make / Model

Vehicle 2 State / Tag #

Is the subject working? If so, where?

Is the subject on modified duties? If so, please provide schedule/hours/restrictions:

Case Details

Employer Name

Claim/File Number

Date of Loss

What is the alleged injury?

Description of Loss / Restrictions

Occupation

Please provide any additional information:

Type of Claim

Workers Comp

Liability

Property

Disability

Auto

Life & Health

Services Requested

eRemote (Unmanned)

Choose Option

Number of Days (3 days min)

Background Investigation

Choose Option

Medical Canvass

Number of Facilities

Enter Type of Facilities

Social Media Investigation

Choose Option

Choose Option

Choose Option

Surveillance (Manned)

Number of Days

Activity Check

Beneficiary Check

Locate

Underwriting Investigation

Alive & Well Check

Document Retrieval

Scene Investigation

Virtual Interview

AOE/COE

Skip Trace (Database Only)

Widow Check

Asset Check

Please provide additional instructions for your service request:

What is the goal of the investigation?

Attachments (Documentation, Images, etc. - Files should be less than 50 MBs in size){This upload form will go here once we add a site plan}

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