Open A Case Please complete the Western Limited Case Intake Form below to the best of your knowledge. Contact Us if you have any questions or need assistance. If you are human, leave this field blank.Client InformationStep 1: Client InformationClient InformationFirst Name *Last Name *Email *Phone Number *Cell PhoneFax NumberAddress *UnitCity *State *AKALARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWYZip Code *Client Company *Job Title *Case InformationStep 2: Case InformationCase InformationInvestigative Service(s) *SurveillanceActivity CheckAOE/COESubrogationRecorded Statement(s)RecordsRecords ReviewBackground CheckSocial Media CheckLocateLocate & ServeOtherAdjustor/Contact *Claim #Due DateTime Authorized for SurveillanceSpecific Days for SurveillanceSend Film in Following Format (Choose all that apply)Email LinkCDDVDFlash DriveDo Not SendDetails of the AccidentObjectives of AssignmentSubject InformationStep 3: Subject InformationSubject InformationChoose OneClaimantSubjectPlaintiffInsuredSubject NameNicknameSubject EmailHome PhoneCell PhoneWork PhoneOther Phone(s)AddressUnitCityStateAKALARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWYZip CodeSSNDOBDOINOIOccupationInjuryPhysical DescriptionGenderMaleFemaleHeightWeightEyesHairEthnicity/RaceAmerican Indian/Alaskan NativeAsianHispanic/LatinNative Hawaiian or Other Pacific IslanderBlack or African-AmericanWhiteNot disclosedLanguages SpokenBuildFacial HairGlassesYesNoOther InformationKnown VehiclesFacebook URLPreviously Investigated?Results of Prior InvestigationSubject Aware of Prior Film?Living SituationFamily InformationAttorney InformationStep 4: Attorney InformationAttorney InformationDefense AttorneyLaw FirmOffice PhoneCell PhoneEmailAddressUnitCityStateAKALARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWYZip CodeEmployer | Insured InfoStep 5: Employer | Insured InformationEmployer | Insured InformationChoose OneEmployerInsuredContactCompanyAddressUnitCityStateAKALARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWYZip CodeEmailPhone NumberOkay to Contact? YesNoSpecial InstructionsStep 6: Special InstructionsSpecial InstructionsInformation for Medical or Legal PickupSpecial InstructionsAttachment 1Attachment 2Attachment 3Attachment 4Submit
