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800.980.9056
info@PhenixNIC.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:

 
2555 Fairview Place, Greenwood, Indiana 46142 • 800.980.9056
© 2010 Phenix Investigations, Inc.
Venue in all disputes is Marion County, Indiana, and Indiana law will be used exclusively as the "choice of law" governing all disputes. Any filings and collection efforts initiated by Phenix Investigations, Inc., will be filed in Marion County, Indiana.