Commercial Index Bureau - Investigative Service Request

COMMERCIAL INDEX BUREAU, INC.
Corporate Headquarters
PO Box 24090
Baltimore, MD 21227

Telephone: (410) 242-8150
Toll Free: (800) 451-0805
FAX: (410) 536-4744

Requestor Information

Name of Requestor:

Company:

Address:

City:

State:

Zip Code:

Phone:

Fax:

E-mail:

Subject:

Date of Loss:

Insured:

Claim #:

Investigation Type

Background Investigation

Civil/Criminal/Court House search

Activities Check

Dependency Check

Hospital Canvas

Surveillance Type (click one)

Other:

Claimant Information

Name:

Social Security #:

Date of Birth:

Occupation:

Address:

Apt or PO Box:

City:

State:

Zip Code:

Home Phone:

Other:

Physical Description:

Nature of Injury:

Budget:

Due Date:

Other Information: (i.e. hobbies, interests, rumors, IME, etc.)

Please contact me for details