You can submit a case request directly to our company using our website!

Simply fill out the information in the fields provided.  If you have any questions or special instructions, please use the comments box.  An ACS representative will contact you shortly.

Your Name:		Your Company:
Phone Number:		Email:
Comments:

*Required Information

*Full Name:		Nick Names:
Social Security #:		Driver's License #:	State:
Address:		*State:	Zip:
City:		Phone:
DOB:	or Age:	Sex:	--FM Hair Color:
Height:	Weight:	Other Physical Info:
Race:	Build:
Marital Status:		Spouse Name:
Dependents:		Vehicle Info:
Alternate Address:		*State:	Zip:
City:		Alternate Phone:
Claim/File #:
Requested Services:	Surveilance Employment Subrogation Activity Check Contestable Death Dependency (Death) Background Interview Medical Specials Locate Records Check Statement Witness Canvass Provider Investigation Other (Specify) AOE/COE
Previous surveillance performed?		Yes No
Alledged Injury: :
Date of Loss:
Physical Limitations: :
Is this person represented by an attorney?		Yes No
Attorney Name:
Address:		State:	Zip:
City:		Phone:
Can we contact the employer?		Yes No
Employer:		Employer Contact:
Address:		State:	Zip:
City:		Phone:
Physician Name:
Address:		State:	Zip:
City:		Phone:
Appointment Dates:		Case Manager:
Defense Attorney:		Phone:
Additional Info:
Objective:
History:
Authorization:
Billing Instructions:
Special Instructions: