J&T Investigations

Excellence Through Performance

Investigation Intake Form

Fill in as many of the fields below as you can and click Submit to email your completed form to us.

Note that fields marked with an "*" are mandatory.

Case Type: *

Re-open Case? *
Yes
No

Case #:

Rush?

Your Name: *

Your Email Address: *

Your Company Name:

Your Street Address: *

Your City: *

Your State: *

Your Zip Code: *

Your Telephone: *

Your Fax:

Claim/Policy#:

Effective Date:

File#:

Subject's Name: *

Subject's Address: *

Subject's City: *

Subject's State: *

Subject's Zip: *

Subject's Telephone:

Subject's Email Address:

Subject's Date of Birth:

Subject's SSN:

Height:

Weight:

Hair color:

Mustache?

Beard?

Glasses?

Sex: *
Male
Female

Race Type: *

Picture?

Date of Injury:

Injury Description:

Insured:

Prior Investigation? *
Yes
No

If Yes, Prior Investigation Date:

Target's Employer at Time of Incident:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Supervisor/Mgr Name:

Employer Telephone:

Employer Email Address:

OK to contact Supervisor?
Yes
No

Target's Compensation at Time of Incident:

Is Physical Contact OK? *
Yes
No

Is Phone Contact OK? *
Yes
No

Neighborhood Canvassing? *
Yes
No

Contact Rep and end of Investigation? *
Yes
No

Cap on Hours/Compensation? *
Yes
No

If Yes, What is that Cap?

Describe What You Would Like Us To Do: *

Any other Notes?

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