Case Assignment Sheet - Perez Investigations, Inc.
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1P
I
, I
.
EREZ
NVESTIGATIONS
NC
1764 – M
CORPORATE OFFICE: P.O. B
, C
94553
OX
ARTINEZ
ALIFORNIA
– C
S
, F
ATELLITE OFFICE
LERMONT
LORIDA
TEL: (925) 934-5543 - FAX: (925) 934-6512 – TOLL FREE: (866) 474-7070
EMAIL:
CASE ASSIGNMENT SHEET
DATE: ________________________________________________
AOE ____ SUB ____ LIB ____ INV ____
COMPANY: ____________________________________________
CLAIM NO.:
______________________
ASSIGNED BY: _________________________________________
PHONE NO.: ______________________
:
________________________________________________________________________________
REPORT TO
SUBJECT NAME: _______________________________________
SS NUMBER: ______________________
ADDRESS: _____________________________________________
PHONE NO.: ______________________
CITY, STATE, ZIP: ____________________________________________________________________________
DOB: __________AGE: _____ HGT: _____ WGT: _____ HAIR: _____ EYES: _____ RACE: _____ MARRIED: _____
AUTO/DMV:
_______________________________________________________________________________
EMPLOYER: _______________________________
JOB DESCRIPTION: _____________________________
ADDRESS: ______________________________________________ PHONE NO.: _______________________
REMARKS: ______________________________________ CONTACT PERSON: ________________________
: ____________________________
INJURY DATE: _____________________________
DESCRIPTION
COMPLAINTS:
____________________________________________________________________________
_____________________________________________________________________________________________
APPOINTMENT: _____________________________________________________________________________
INSTRUCTIONS: _____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________
OUR FILE NO. __________________
SS TRACE: ______ DMV: ______ CIVIL: ______ CRIMINAL: ______ EDEX: ______ OTHER: ______
MAILING ADDRESS: P.O. Box 1764. Martinez, CA 94553 · Telephone (925) 934-5543 · Fax (925) 934-6512
California & Florida Statewide Agency · Toll Free (866) 474-7070 ·
CA Lic. # PI22956 · FL Lic. # A1600161
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