Investigation Order Form

Thank you for choosing SIU Consultant Group for your investigation needs. Please complete the below referral form. Claim information will be securely submitted and a Case Manager will contact you shortly.

You can also register online, which enables you to check the status of all open cases, open new investigations, view reports, view case notes, view streaming video and listen to recorded audio. Click here to register. If you need immediate assistance or have any further questions, please call us at (888)748-1130.

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Client Information

Company

First Name

Last Name

Address

Address 2

City

State

Select option AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip

Phone

Email

Assignment Information

Type of Assignment

Select option Workers Comp Liability Disability Auto Legal Other

Case Instructions/Objectives

Due Date

-MM- 01 02 03 04 05 06 07 08 09 10 11 12 /  -DD- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  -YYYY- 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Claim Number

Date of Incident

-MM- 01 02 03 04 05 06 07 08 09 10 11 12 /  -DD- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  -YYYY- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Injury/Body Part

Restrictions

Employer/Insured

Upcoming RUSH Events

Select option Medical Deposition Hearing Special Event Other

Services Requested

Please Select Service

Select option Surveillance Activity Check Alive and Well Check Recorded Statements Background Social Media Research Asset Research Medical Canvass Fraud Investigation Skip Trace Records Research & Retrieval

Number of Days

Employee Only
Employee
Witnesses
Employer


Select option Hospital Clinic Pharmacy

Medical Release

Select option Yes No

Searches

Select option 12 24 48 Other

Attachment

Attach your File

NOTE: You may submit claim documents, photos and or medical records.

Claim Information




Subjects First Name
Subjects Middle Name
Subjects Last Name
Social Security Number
Date of Birth
-MM- 01 02 03 04 05 06 07 08 09 10 11 12 /  -DD- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  -YYYY- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Address
Apt #
City
State
Select option AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip
Home Phone
Cell Phone
Gender
Select option Male Female
Race
Height
Weight
Hair
Eye
Marital Status
Select option Single Married Divorced
Children
Yes
No

Additional Information
Attorney Represented
Yes
No

Defense Attorney Name
Defense Attorney Phone
Treating Physician Name
Medical Office Name
Medical Office Address
Medical Office Phone
Date of Medical Appointment
-MM- 01 02 03 04 05 06 07 08 09 10 11 12 /  -DD- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  -YYYY- 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
Time of Appointment
HH 01 02 03 04 05 06 07 08 09 10 11 12 :  MM 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM
Job Description
Current Work Status
Select option Off Work Light Duty Terminated Full Duty Other
Special Instructions
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