Investigation Request Form
 

  In order to assist you in the most effective manner possible,
please use the following Investigation Request Form. Please provide
our office with detailed and specific information, this will enable us to
understand the nature of your request and help us assist you in a
more timely and efficient manner.

NOTE : All requests and information you submit to NIA will be held in
the strictest confidence. If you prefer, our address, phone and
fax information can be found here or you can send an e-mail toCorporate@niaintel.com.

Use the Following Form to Place an Order

 
Type of Investigation:
 INSURANCE
 CORPORATE
 PRIVATE 
 OTHER
Description:
 
 Surveillance (Video and Still Photos)
 Countermeasures (Debugging and Security Consulting)
 Activity Check / Records Check / Locate / Statements
 Other
 
CLIENT INFORMATION:
       *Name: 
    Company: 
 
			    *Address 1: 
  Address 2: 
       
			   *City:  
			   *State: 
   
			   *Zip Code:  Country: 

Voice Phone: 
        Fax: 
      
			   *Email: 
How would you like to be contacted by our office:
Telephone 
E-mail
 Other  Specify: 
How often do you want to be contacted by our office:
Who is to be updated:
 
CASE INFORMATION:
Today's Date       Date Needed By   
Trial/Hearing Date       Budget   
What is the nature of your problem ?
Why do you think there is a problem ?
Special Instructions :
Subject of Investigation :
Subject/Claimant: 
Alias:  
Subject's Address:
   
Phone Number  
Date of Birth    
Social Security Number  
Race/Sex   Height    Weight  
Physical Description: 
                      
Marital Status:      
Spouse's Name: 
Subject's Vehicles and License Tag Numbers:

Alleged Injury:

Physical Restrictions:


     
Type of Claim: 


    
Date of Loss:    
Insured:     
Is the Subject Represented? 
Name of Attorney and Firm?   
Physician Information:    
Previous Surveillance Performed?     
If yes, when  
Outcome/Notes from Previous Surveillance: