Order Report

How to Place an Order

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Note: If you do not receive a separate email acknowledgment after submission of this order form,
please call us within the next 24 hours at 336-288-3655.
Choose Report Type*
Name*
First Last
Title*
Company*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Email*
Date of Loss
MM slash DD slash YYYY
File No.*
Insured/Client
SUBJECT INFORMATION
Subject's Name*
First Last
Subject's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date of Birth*
MM slash DD slash YYYY
Age
Social Security number
Driver's License Number
State
SUBJECT EMPLOYMENT INFORMATION
Name of Last Known Employer
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
REPORT INFORMATION
RUSH Request?*
- Yes
- No
Is File Address Current?
- Yes
- No
- Unknown
What you are looking for? What are the Claim Details?
How do you want to receive the report once completed?
- Save to Client Portal
- Fax me the Report
- Other
How did you hear of us?*
If other please explain.
IMPORTANT
Documents can be uploaded by clicking here after the form has been submitted or you may fax, if available, to us toll-free at 888-390-7094.
A cover sheet is not necessary.
Thank you!
Consent
I agree to the HIPAA Privacy Statement

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