American Eagle Investigation - 211 Indiana Drive, Pleasantville, IA 50225

American Eagle Investigations, Inc. Surveillance Order Form
211 Indiana Drive, Pleasantville, IA 50225
Phone 515-848-3401 || Fax 515-848-5242 || Toll-Free 800-550-7878

______________________________________________
Company Requesting Investigation/Surveillance

_______________
Date

_________________
Type of Claim

______________________________________________ Mailing Address	_________________________________________ Adjuster
______________________________________________ City/State/Zip	_________________________________________ Claim #

______________________________________________
Phone Number and Extension

_______________
Deadline

$_________________
Authority

______________________________________________
Fax #

________________________________________
Surveillance last conducted

CLAIMANT
___________________________________________________ Name	_______________ DOB	_________________ SSN

________________________________________________________________________________
Address

City ______________________

State ______

Zip _________

Phone _________________________

______________________________________________
Previous Address

_________________________________________
Spouse/Children information

______________________________________________
Identifying Characteristics - Height/Weight

glasses

facial hair

tatoos

______________________________________________

Hair _____________________________________

___________________________________________________________________ Injury	________________ Injury Date
___________________________________________________________________ Restrictions/Limitations	Atty.? Yes No

______________________________________________
Employer

____________________________________________
Employer Address

Contact Yes No

______________________________________
Employer Phone

_____________________________
Contact Person

DOCTOR ______________________________________________ Doctor's Name	THERAPY ____________________________________________ Therapy Name
______________________________________________ Doctor's Address	____________________________________________ Therapy Address
______________________________________________ Phone #	____________________________________________ Phone #
______________________________________________ Next Appt.	____________________________________________ Next Appt.

CASE INSTRUCTIONS

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continue on blank space if necessary

Applying for surveillance services does not guarantee that a case will be taken.

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