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Claim Number / Case Number

Type of Loss / Injury

Date of Loss / Injury (if applicable)//

Medical Provider / Physician of Record (POR) (if applicable)

Upcoming Appointments / Known Future Locations

Physical Restrictions

Service Request Type *

Tracking Duration:

Daily (12 days)
Weekly (12 weeks)
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Canvass Locations / Radius: *

Number of Locations: *

25
32

Location Type/s: *

Canvass Search Address

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Red Flags (What led you to suspect abuse, fraud, and/or wrongdoing?) *

Budget *

Your answer should include the total dollar amount you'd like to spend or the number of surveillance days

Objectives *

Special Instructions

Do you have additional documents to provide? Upload them here (Medco 14, previous investigations, pictures):

Click or drag a file to this area to upload.

Due Date / Deadline//

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Employer's Information

CURRENT CLIENTS

KINGS

CONTACT INFO

CINCINNATI

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