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Client Name *

First

Last

Company / Attorney / Adjuster

Client Phone Number *

Preferred Contact MethodPhone CallsText MessageEmail

Client Address *

Client Email *

IME Employer Attorney

DLI Services Needed *— Select Choice —SurveillanceProcess ServiceBackground CheckDomestic InvestigationInsurance InvestigationEmployment VerificationSocial Media SearchOther

Subject's Name *

First

Last

Subject's Address *

Subject's Date of Birth (DOB) *

Subject's SS#

Subjects Description

Describe the subjects: hair, color, height, weight, sex, other.

Subject's Attorney

Subject's Vehicle 1 / License Plate#

Subject's Vehicle 2 / License Plate #

Subject's Employer

Address of Employer

Subject's Injuries

Date of Accident

Doctor or Health Care Provider 1

Doctor or Health Care Provider 2

Scheduled Doctor Appointments

IME / Surgery Dates

Reason For Investigation

Specific Objectives / What Would You Like Us to Determine?

Known Addresses / Locations

Additional Information / Special Instructions

Please provide any additional information, instructions, concerns, or details you believe may be important to this investigation.

Client Authorization *

• I certify that the information I have provided is true and accurate to the best of my knowledge, and I authorize Dugas Legal Investigations to contact me regarding the requested investigation and services.

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