Private Investigations

Referral Form

* Email

* First Name

* Last Name

* Company

* Address street Address

Apt, Suite, Bldg. (optional)

* City

* State / Province / Region

* Postal / Zip Code

* Country

Account #

* Phone

* Email

Fax

Claimant Information

* First Name

Middle Initial

* Last Name

* Address street Address

Apt, Suite, Bldg. (optional)

* City

* State / Province / Region

* Postal / Zip Code

* Country

Phone

Alt Phone

* DOB

* SSN

* Height

* Weight

* Build

Work Schedule

Employer Information

* Employer / Company

* Address street Address

Apt, Suite, Bldg. (optional)

* City

* State / Province / Region

* Postal / Zip Code

* Country

Contact Name

* First

* Contact Phone

* Contact Email

Contact Fax

Case Information

Claim No.

DOI

Injury Description

Is Claimant Represented?

Yes

Select any or all services you need

Surveillance

Medical Record Check

Background Check

Social Media Check

Other

Pleae describe

Remark / Specific Information Request

If you have any remarks or specific information i.e. case hours, days, times, etc. you would like to request, please let us know in the field below.

DISCLAIMER & CERTIFICATIONS

By the client's acceptance of an Investigative Report, the client agrees to indemnify and hold harmless ACTA-PANNELL, its officers, employees and service providers from all errors, omissions and against any and all claims and liability resulting from the use of this report. ACTA-PANNELL and vendors utilized by ACTA-PANNELL in preparing this report, certify that during the course of the investigation, it maintained full compliance with the FCRA, GLB, DPPA and HIPAA. ACTA-PANNELL is Fully Licensed and Insured Private Investigation Agency License #C-1633 All of our agents are registered with the Texas Department of Safety Private Security Bureau.