American Eagle  Investigations, Inc. Surveillance Order Form
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

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

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