Claim Investigation Request

Claim Investigation Request Form

Please fill in the following form as completely as possible in order to initiate a claim investigation. Alternatively, you may download our ClaimInvestigation.pdf form, fill it in and fax it back to 705·722·5829

Client Information:
Client Name: (company)
Client Address:
No. & Street:
Suite:
City:
Province:
Postal Code:
Contact Person:
Contact Email:
Contact Telephone:
Contact Fax:

Claimant Information:
Insured:
Claim #:
Date of Loss:
Insurance Adjuster:

Third Party Information:
Third Party Name:
Third Party Address:
City:
Province:
Postal Code:
Third Party Telephone:
Third Party S.I.N.:
D.O.B.: (MM/DD/YYYY)
Third Party Height:
Third Party Weight:
Third Party Description:
Third Party Sex:	Male Female
Third Party Status:	Single Married Separated Common-law Divorced

Vehicle Information:
Driver's License #:
Other Identification:
Vehicle #1 Description:
Vehicle #1 Plate #:
Vehicle #2 Description:
Vehicle #2 Plate #:

Professional Information:
Employer Name:
Employee Position:
Employer Address:
Employer Phone:

Doctor's Name:
Doctor's Address:
Doctor's Phone:

Physio/Rehab Name:
Physio/Rehab Address:
Physio/Rehab Phone:

Lawyer's Name:
Lawyer's Address:
Lawyer's Phone:

Nature of Disability:

Instructions:
Services:	Activities Check Locate Background Finance Subrogation
Surveillance:	Number of Days Video Documentation 35 mm Documentation
Previous Accidents:
Statements:
Other Requests:
Investigation $ Limit:

"Your Thoughts":
Comments/Requests:
Please supply any additional pertinent documentation (ie. Credit Bureau, Driver's Abstract, etc) via fax: 705·722·5829
If you prefer to print and fax-back a form, you may download it here: ClaimInvestigation.pdf This printable form requires Adobe Acrobat Reader to open. You may download Acrobat Reader here.

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The Renwick Group Inc.
Corporate Office: 93 Dunlop Street East, Suite 301, Barrie, ON, Canada, L4M 1A8
Tel: (705)722-9807 Fax: (705)722-5829 Email: info@renwickgrp.com

The Renwick Group Inc. is a fully licensed, bonded and
insured private investigation service corporation.

Updated Mar 2004

Claim Investigation Request Form

The Renwick Group Inc. is a fully licensed, bonded and insured private investigation service corporation.

The Renwick Group Inc. is a fully licensed, bonded and
insured private investigation service corporation.