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800.980.9056
info@phenixinvestigations.com
Investigation Request Form

You can assign a case to Phenix by choosing one of these options:

  1. Call us at 800-980-9056 to speak with an investigator
  2. Download a Case Assignment sheet (to be faxed or mailed)
  3. Complete the online form below
*Indicates required field

Date:  

Type of Investigation    Other:   

Number of Days Requested: surveillance only 

Contact Information
*Contact Person:   
*Company/Firm:   
*Title:   




*Phone #:   
*E-mail:   
*Fax #:   




*Address:   
*City:   
                              *State:       *Zip:   

Other Contacts: 

Are you representing a client?  Yes No   

If so, what client?   
Client Contact:   
Client Phone:   


Corporate Clients:  How is your company insured?
What carrier?  


*How did you hear about Phenix?   
If referred, who referred?    


Subject's Information
Subject's Name:   
Claim Number:   




Phone #:   
Date of Birth:   
Social Security #:   (no dashes)




Subject's Address:   
City:   
                               *State:      *Zip:   


Alleged Injury - if applicable:    
Date of Loss:   


Marital Status:  M S D    Number of Children: 


Physical Description
Male Female   Race  

Height:    Weight:   
Additional characteristics:  


Has case been worked by another firm?   YesNo
Has subject retained counsel?   YesNo
Is subject receiving medical treatment?   YesNo
If so, where?   


Date of next medical appointment?   
Time of next medical appointment?   

Additional Information:

 
Phenix provides services Nationally and Internationally
6838 South East Street • Indianapolis, Indiana 46227 • 800.980.9056
© 2008 Phenix Investigations, Inc.